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URINARY 

ANALYSIS AND DIAGNOSIS 

BY MICROSCOPICAL AND CHEMICAL 
EXAMINATION 



BY 

LOUIS HEITZMANN, M.D. 



NEW YORK 



SeconD IReviseD anfc BnlargeD Bfcttfon 



WITH ONE HUNDRED AND THIRTY-ONE ILLUSTRATIONS, 
MOSTLY ORIGINAL 



NEW YORK 

WILLIAM WOOD AND COMPANY 

MDCCCCVI 



LIBRARY of CONGRESS 
One Copy Received 
JAN 15 1906 

_ Cooyrtint Entry . 

/S.ASS a. XXC.NO, 

if / S *~*~4 ST 

COPY 8, 



7?353 



Copyright, 1906, 
By WILLIAM WOOD & COMPANY 






Go tbe Memory 



MY FATHER 
CARL HEITZMANN, M.D. 

WHOSE LIFE-WORK WAS DEVOTED 

TO THE 

SCIENCE OF MEDICINE 

THIS VOLUME IS AFFECTIONATELY 

5>eoicateo~ 



PREFACE TO THE SECOND EDITION. 



Since the appearance of the first edition of this work, more than six 
years ago, many advances have been made in the chemical analysis of 
urine, while microscopical examination and especially microscopical 
diagnosis still receive comparatively scant attention in most text-books 
on this subject. Many years of experience and teaching have shown the 
author that correct diagnoses by means of microscopical examination 
of urine can frequently be made in cases where other methods are of 
little or no practical value. 

In the revision of this work, the aim has been to increase and im- 
prove the first part on chemical examination, and to incorporate in it 
all the simpler methods and tests which have proven of value as an 
aid to urinary diagnosis in the hands of different authors. The more 
complicated tests, however, which can only be carried out in completely 
fitted chemical laboratories, and are described in the larger text-books on 
the chemistry of urine, have been omitted. The author here desires 
to express his thanks to Mr. Karl Schnackenberg, Ph.G., for his many 
valuable suggestions and proof-reading of this part of the work. 

The greatest stress has been laid upon the microscopical examina- 
tion and especially the microscopical diagnosis. In many cases in which 
the clinical symptoms, although pointing to an affection of the genito- 
urinary tract, are vague, and even with the aid of chemical analysis 
of the urine will not admit of a positive diagnosis, microscopical exami- 
nation, if carefully conducted, will completely clear up the case. It is 
evident that a mere description of the features found in different cases 
cannot be sufficiently clear, but that illustrations made directly from 
nature are absolutely essential. In the present volume the illustrations 
have been drawn by the author directly from specimens in his possession. 
They have been increased in number in this edition, while some of the 
old illustrations were replaced by others. The text has been carefully 
revised and additions made where it was deemed advisable. 



vi PREFACE TO THE SECOND EDITION. 

In the third part, devoted to microscopical diagnosis, full-page illus- 
trations have been added to elucidate the text, each drawing giving the 
different features in the case it depicts. This subject is undoubtedly 
of the greatest practical value, and a careful study of the different for- 
mations seen in urine cannot fail to show the importance of urinary 
diagnosis. Many mooted points in the clinical symptoms can often be 
cleared up by the microscope in a short space of time, and correct con- 
clusions as to the exact condition of the patient arrived at. The author 
hopes that this volume may serve a useful end, and will consider his 
labors amply rewarded if he has thereby succeeded in simplifying an 
extremely important branch of Microscopy. 

Louis Heitzmann. 

New York, December 1, 1905. 






CONTENTS 



Introductory 

CHAPTER I 

PAGE 

Histology and Secretion 1 

CHAPTER II 
General Remarks 8 



PART FIRST 
Chemical Examination 

CHAPTER III 
General Physical and Chemical Properties (page 13) 

Normal Urine 13 

Color of Normal Urine 13 

Amount of Urine 14 

Consistency and Odor 14 

Solid Constituents of Normal Urine 15 

Urinary Pigments or Coloring Matters 15 

Gaseous Constituents 16 

Changes Upon Standing 16 

Color of Urine under Pathological Conditions 16 

Sediment 17 

Amount of Urine under Pathological Conditions 17 

Determination of Specific Gravity 17 

Determination of Solids 19 

CHAPTER IV 

Normal Constituents (page 20) 
A. Organic (page 20) 

Urea 20 

Quantitative Tests 22 

Uric Acid 24 

Purin Bodies 25 

Creatinin „ . 26 

vii 



viii CONTENTS. 

PAGE 

Hippuric Acid 

Kthereal Sulphates 27 

Coloring Matters 27 

Urochrome 

Haematoporphyrin 2 ' 

Uroerythrin 27 

Urobilin 28 

B. Inorganic (page 28) 

Chlorides, 28 

Phosphates ...» 30 

Sulphates 31 

Carbonates . 33 

Centrifugal Analysis 33 

Estimation of Chlorides 33 

Estimation of Phosphates 33 

Estimation of Sulphates 34 

CHAPTER V 

Albuminous Substances (page 35) 

Albuminuria 35 

Detection of Albumin in Urine 36 

1. Heat Test with Acetic Acid 36 

2. Heat Test with Nitric Acid 38 

3. Heller's Test 38 

4. Potassium-Ferrocyanide Test . 38 

5. Spiegler's Test 39 

6. Sulpho-Salicylic-Acid Test 39 

7. Biuret Reaction 39 

8. Picric-Acid Test 39 

Quantitative Tests for Albumin 40 

Globulin 42 

Albumoses 42 

Peptones 43 

Mucin (Nucleo-Albumin) 44 

Fibrin 44 

CHAPTER VI 

Carbohydrates (page 46) 

A. Grape Sugar (page 46) 

( Ira pe Sugar, Dextrose, or Glucose 46 

Detection of Sugar in Urine 47 

1 . Moore-Heller Test 47 

2. Trommer's Test 47 

3. Fehling's Test ! '.'.'.'. 48 

1. Haines' Test 43 

5. Bottger's Test 49 



CONTENTS. ix 

PAGE 

6. Phenylhydrazin Test 49 

Quantitative Tests for Sugar 49 

Fehling's Test 49 

Robert's Fermentation Test 50 

Einhorn's Fermentation Saccharometer 50 

B. Other Carbohydrates (page 51) 

Fruit Sugar, Levulose 51 

Milk Sugar, Lactose 51 

Maltose or Isomaltose 52 

CHAPTER VII 

Other Abnormal Constituents (page 53) 

Acetone 53 

Diacetic Acid 54 

B-Oxybutyric Acid 54 

Indican 55 

Ehrlich's Diazo Reaction 55 

Coloring Mattert 56 

Bile Pigments 56 

Coloring Matter of Blood 57 

Haematoporphyrin 58 

Melanin 58 

Fatty Matters . 58 

Leucin and Tyrosin 59 

Cystin 59 

PART SECOND 
Microscopical Examination 

CHAPTER VIII 

General Considerations (page 63) 

Use of Centrifuge 64 

Mounting of Sediment 66 

Use of Antiseptic Substances 66 

Preservation of Sediment 66 

Magnifying Powers 67 

CHAPTERJX 

Crystalline and Amorphous Sediments (page 69) 
I. Acids and Salts (page 69) 

A. Acid Sediments < . . 69 

1. Uric Acid 69 

2. Sodium Urate 75 

3. Calcium Oxalate . - .76 



x CONTENTS. 

PAGE 

4. Cystin . . . ' ' ' ' l 9 

7Q 

5. Creatinm /y 

6. Hippuric Acid • 

7, 8. Leucin and Tyrosin • 82 

9. Calcium Sulphate 83 

B. Alkaline Sediments 83 

1. Triple Phosphates 83 

2. Simple Phosphates 86 

3. Ammonium Urate 88 

4. Calcium Carbonate 90 

5. Magnesium Phosphate 91 

II. Other Unorganized Sediments (page 91) 

Fat • 91 

Cholesterin 92 

H^rmatoidin 93 

Indigo • 94 

Melanin 95 

Urinary Concretions (page 95) 



CHAPTER X 

Blood-Corpuscles and Pus-Corpuscles (page 97) 

I. Blood-Corpuscles (page 97) 

Red Blood-Corpuscles or -Globules 97 

White Blood-Corpuscles or Leucocytes 98 

Fibrin 98 

Blood-Clots 99 

II. Pus-Corpuscles (page 100) 

Constitution 102 

CHAPTER XI 

Epithelia (page 105) 

Kpithelia Common to Both Sexes '. 107 

Epithelia from the Bladder 107 

Epithelia from Pelvis of Kidney 109 

Epithelia from the Ureters ..*... 110 

Epithelia from the Uriniferous Tubules of Kidneys . .110 

Epithelia found in Urine of Male 113 

Epithelia from Urethra ...,,, 113 

Epithelia from Prostate Gland . . . 113 

Epithelia from Seminal Vesicles 115 

Epithelia from Ejaculatory Ducts 115 

Sperma 116 

Urethral and Gleet-Threads 116 

Epithelia Found in Urine of Female 119 

Epithelia from Vagina 119 

Smegma 119 



CONTENTS. xi 

PAGE 

Epithelia from Bartholinian Gland 120 

Epithelia from Cervix Uteri 120 

Epithelia from Mucosa Uteri 121 

CHAPTER XII 

Mucus and Connective Tissue (page 123) 
I. Mucus (page 123) 

II. Connective Tissue (page 125) 

1. Ulceration 127 

2. Suppuration „ 127 

3. Hemorrhage 128 

4. Traumatism . 128 

5. Tumors 129 

6. Hypertrophy of Prostate Gland 130 

7. Stricture of Urethra 130 

8, 9. Cirrhosis and Atrophy of Kidney 131 

! 10. Intense Inflammations 131 

CHAPTER XIII 

Tubular Casts (page 132) 

I. True Casts (page 133) 

1. Hyaline Casts ... 134 

2. Epithelial Casts 136 

3. Blood-Casts 137 

4. Granular Casts . v ■ . . 137 

5. Fatty Casts 140 

6. Waxy Casts 141 

7. Mixed Casts , 143 

Other Casts 143 

II. False or Pseudo Casts (page 144) 

Urate Casts 144 

Bacterial Casts 146 

Pus-Casts 146 

Fat-Casts 146 

Fibrin-Casts 146 

CHAPTER XIV 

Micro-organisms and Animal Parasites (page 147) 
I. Micro-organisms, or Fungi (page 147) 

Non-pathogenic Micro-organisms 147 

1. Mould Fungi 147 

2. Yeast Fungi 148 

3. Fission Fungi ,,,.... 150 



Xll 



CONTENTS. 



. _, , . . 151 

Pathogenic Schizomycetes l52 



Gonococci 
Other Cocci . 
Tubercle Bacilli 



155 
155 

158 



Typhoid Bacilli 

Bacterium Coli Commune '*„?!! 

Actinomyces 

II. Animal Parasites, or Entozoa (page 160) 



159 



Trichomonas Vaginalis 

Echinococci 

Distoma Haematobium 
Filaria Sanguinis Hominis 
Ascaris Lumbricoides . . 
Other Parasites . . . . 



160 
161 
162 
163 
164 
165 



167 
167 



CHAPTER XV 

Extraneous Matters (page 166) 

Cotton Fibres 

Linen Fibres 

Silk Fibres 

Wool Fibres • 167 

Human Hairs 16 ' 

Feather 168 

Scales from Moth 169 

Starch-Globules 17 ° 

Lycopodium . . 170 

Cellulose 171 

Cork " 173 

Oil-Globules and Air-Bubbles 173 

Flaws in Glass 173 

Vegetable Matter 175 

Fieces 176 



PART THREE 
Microscopical Urinary Diagnosis 

Introductory 179 

CHAPTER XVI 

Diseases of the Kidney and Pelvis (page 181) 

I. Inflammations of the Kidney and Pelvis (page 181)- 

Classification 181 

Pathological Changes 184 

1. Catarrhal Inflammation 184 

2. Croupous Inflammation 185 

3. Suppurative Inflammation 188 



15 

15'.' 
IS 






CONTENTS. xiii 

PAGE 

Congestion or Hyperemia of the Kidney 187 

Causes 187 

Catarrhal or Interstitial Nephritis 188 

Causes 188 

Clinical Symptoms 189 

Features Found in Urine 189 

Acute Catarrhal or Interstitial Nephritis 193 

Chronic Catarrhal or Interstitial Nephritis 193 

Subacute Catarrhal Nephritis 194 

Cirrhosis of the Kidney 197 

Catarrhal Pyelitis 197 

Ureteritis 198 

Croupous or Parenchymatous Nephritis 198 

Causes „ ..... 198 

Clinical Symptoms 201 

Features Found in Urine 201 

Acute Croupous or Parenchymatous Nephritis 202 

Subacute Croupous Nephritis 206 

Chronic Croupous Nephritis 206 

Atrophy of the Kidney 212 

Chronic Croupous Nephritis with Acute Croupous Exacerbation . . . 217 

Suppurative Nephritis 218 

Causes 218 

Clinical Symptoms 221 

Features Found in Urine 221 

Suppurative Pyelitis 222 

Tuberculosis of the Kidney 225 

Features Found in Urine 225 

II. Anomalies of Secretion (page 229) 

Causes 229 

Clinical Symptoms 229 

Lithcemia 229 

Hemorrhage from the Pelvis of the Kidney 230 

Pyelitis Calculosa 233 

Oxaluria 233 

Hcemoglobinuria 234 

Causes 234 

Features Found in Urine 234 

Chyluria 239 

Features Found in Urine 240 

III. Malignant Tumors of the Kidney (page 243) 

Clinical Symptoms 243 

Appearance of Urine 243 

Sarcoma 243 

, Features Found in Urine 244 

Cancer 247 



xiv CONTEXTS. 

CHAPTER XVII 

Diseases of the Bladder (page 248) 
I. Inflammations of the Bladder (page 248) 

PAGE 

Causes 248 

Clinical Symptoms 249 

Appearance of Urine ' . . 250 

Catarrhal Cystitis 250 

Microscopical Features 250 

Acute Catarrhal Cystitis 250 

Chronic Catarrhal Cystitis 254 

Subacute Catarrhal Cystitis 257 

Ulcerative Cystitis 257 

Acute Ulcerative Cystitis 257 

Chronic Ulcerative Cystitis 258 

Suppurative Cystitis : 258 

Pericystitis 263 

II. Tumors of the Bladder (page 264) 

Clinical Symptoms 264 

Papilloma 264 

Microscopical Features 264 

Sarcoma 268 

Microscopical Features 268 

Carcinoma 268 

Microscopical Features 271 

III. Parasites in the Bladder (page 272) 

CHAPTER XVIII 

Diseases of the Sexual Organs (page 275) 

Urethritis 275 

Acute Urethritis 275 

Chronic Urethritis 275 

Prostatitis 276 

Causes 276 

Clinical Symptoms 276 

Features Found in Urine 277 

Acute Prostatitis m 277 

Chronic Prostatitis 278 

Hypertrophy of the Prostate Gland . 283 

Tuberculosis 283 

Tumors ... 2«4 

Spermatorrhoea . . ' 2 c4 

Seminal Vesiculitis 2 Q7 

Clinical Symptoms 287 

Features Found in Urine 287 



CONTENTS. xv 

PAGE 

Vaginitis 293 

Features Found in Urine 293 

Catarrhal Vaginitis 293 

Ulcerative Vaginitis 294 

Traumatic Vaginitis 294 

Cervicitis and Endometritis 299 



CHAPTER XIX 

Determination of the Functional Efficiency of the Kidneys (page 301) 

Cryoscopy 301 

Methylene-blue Test 302 

Phloridzin Test . . .^ 302 

Toxicity Test 303 

Electric Conductivity 303 

Appendix 305 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Malpighian Corpuscle 2 

2. Diagram of the Kidney . 3 

3. Cortical Substance of the Kidney. Transverse Section. Blood- Vessels 

Injected 4 

4. Medullary Substance of the Kidney. Transverse Section. Blood- Vessels 

Injected 4 

5. Injected Blood-Vessels of the Cortical Substance of the Kidney of a Dog . 5 

6. Urinometer . , . 18 

7. Pyknometer 19 

8. Crystals of Urea and Nitrate of Urea 21 

9. Doremus' Ureometer 22 

10. Hinds' Modification of Doremus' Ureometer . . . 23 

11. Horismascope 40 

12. Esbach's Albuminometer 40 

13. Einhorn's Fermentation Saccharometer 50 

14. Sedimentation Glass 63 

15. Spaeth's Sedimentation Glass 63 

16. Hand Centrifuge ... 64 

17. Water-power Centrifuge 64 

18. Sedimentation Tubes for Centrifuge 65 

19. Crystals of Uric Acid, Common Form ............. 70 

20. Crystals of Uric Acid, Common Form . 71 

21. Crystals of Uric Acid, from Highly Acid Urine ......... 72 

22. Uric-Acid Concretions . ... 73 

23. Pale Uric- Acid Crystals 74 

24. Sodium Urate, Amorphous . . . . 75 

25. Sodium Urate, Crystalline 76 

26. Granules of Sodium Urate Changing to Globules and Dumb-Bells ... 77 

27. Calcium Oxalate Crystals 78 

28. Cystin Crystals .79 

29. Creatinin Crystals 80 

30. Sediment in the Urine of an Athlete ............. 80 

31. Hippuric Acid 81 

32. Leucin and Tyrosin 82 

33. Calcium Sulphate Crystals ................ 83 

34. Complete Triple Phosphates ................ 84 

35. Incomplete Triple Phosphates 85 

36. Amorphous Simple Phosphates 86 

37. Star-shaped Simple Phosphates 87 

38. Ammonium Urate 88 

39. Acid Sediment in Fermentation and in Transition to Alkaline .... 89 

40. Calcium Carbonate and Magnesium Phosphate 90 

41. Fat-Globules and Margaric-Acid Needles . 91 

xvii 



xviii LIST OF ILLUSTRATIONS. 

FIG. PAGE 

42. C'holesterin Crystals 93 

43. Fhematoidin Crystals 93 

44. Indigo Crystals 94 

4."). Blood-Corpuscles / 98. 

46. Fibrin and Blood-Clot 99 

47. Pus-Corpuscles 101 

48. Pus-Corpuscles Showing Different Constitutions 102 

49. Epidermal Scales 107 

50. Kpithelia from the Bladder 108 

51. Epithelia from Pelvis of Kidney and Ureter 110 

52. Kpithelia from Uriniferous Tubules of Kidneys Ill 

53. Comparative Sizes of Corpuscles and Epithelia 112 

54. Kpithelia from Urethra 113 

55. Epithelia from Prostate Gland, Seminal Vesicles, and Ejaculatory Ducts . 114 

56. Sperma as Found in Urine 115 

57. Gleet-Threads 117 

58. Epithelia from the Vagina 118 

59. Smegma from the Clitoris 120 

60. Epithelia from Bartholinian Gland, Cervix Uteri, and Mucosa Uteri . . 121 

61 . Mucus-Threads and -Corpuscles , 124 

62. Mucus-Casts or Cylindroids 125 

63. Connective-Tissue Shreds 126 

64. Connective-Tissue Shreds Found in Tumors 129 

65. Hyaline Casts 135 

66. Epithelial Casts 136 

67. Blood Casts 138 

68. Granular Casts 139 

69. Fatty Casts 140 

70. Waxy Casts 141 

71. Mixed Casts 142 

72. ( lasts of Ammonium Urate and Sodium Urate 144 

73. False or Pseudo Casts 145 

74. Oidium Lactis 148 

75. Penicillium Glaucum and Aspergilli 149 

76. Saccharomycetes 150 

77. Schizomycetes 151 

78. Acute Gonorrhoea 153 

79. Chronic Gonorrhoea 154 

80. Tuberculosis of the Kidney 157 

81. Bacterium Coli Commune 158 

82. Actinomyces _ I59 

83. Trichomonas Vaginalis 160 

84. Portions of Echinococcus 161 

85. Ova of Distoma Haematobium 162 

86. Filaria Sanguinis Hominis 163 

87. Ova and Portion of Ascaris Lumbricoides 164 

88. Col Ion Fibres 166 

89. Linen Fibres 16 y 

90. Silk Fibres 168 

91 Wool Fibres ' 168 



LIST OF ILLUSTBATIOm. xix 

PAGE 

Feather 169 

Scales from Wings of Moth 169 

Starch Globules 170 

Lycopodium Globules 171 

Cellulose 171 

Cork 172 

Oil-Globules and Air-Bubbles 172 

Flaws in the Glass 173 

Vegetable Matter , 174 

Normal Faeces 175 

Acute Catarrhal Pyelo-nephritis (Acute Interstitial Nephritis) and Cystitis 191 
Chronic Catarrhal Pyelo-nephritis (Chronic Interstitial Nephritis) and 

Cystitis 195 

Cirrhosis of the Kidney, with Chronic Catarrhal Cystitis 199 

Acute Croupous or Parenchymatous Nephritis, with Catarrhal Pyelitis and 

Cystitis 203 

Acute Hemorrhagic Croupous or Parenchymatous Nephritis, with Catar- 
rhal Pyelitis and Cystitis . 207 

Subacute Croupous or Parenchymatous Nephritis, with Catarrhal Pyelitis 

and Cystitis 209 

Chronic Croupous or Parenchymatous Nephritis, with Fatty Degeneration 

of the Kidney, Accompanying Catarrhal Pyelitis and Cystitis . . .213 
Chronic Croupous or Parenchymatous Nephritis, with Fatty and Waxy 

Degeneration of the Kidney, Accompanying Catarrhal Pyelitis . .215 
Chronic Croupous or Parenchymatous Nephritis, with Fatty and Waxy 
Degeneration of the Kidney and an Acute Hemorrhagic Croupous 

Exacerbation, Catarrhal Pyelitis, and Cystitis 219 

Chronic Suppurative Nephritis, with Catarrhal Pyelitis 223 

Acute Abscess of Pelvis of Kidney, or Acute Suppurative Pyelitis . . . 227 

Lithsemia, with Subacute Catarrhal Pyelitis and Cystitis 231 

Hemorrhage from Pelvis of Kidney, Due to Uric-Acid Calculus .... 235 
Hemoglobinuria, Acute Hemorrhagic Croupous or Parenchymatous Neph- 
ritis, with Catarrhal Pyelitis 237 

Chyluria, Catarrhal Cystitis 241 

Sarcoma of Kidney, Chronic Catarrhal Pyelitis and Cystitis 245 

Acute Catarrhal Cystitis 251 

Chronic Catarrhal Cystitis 255 

Acute Ulcerative Cystitis 259 

Chronic Ulcerative Cystitis 261 

Pericystitis, Due to Parametritis 265 

Hemorrhage from the Bladder, Due to Papilloma of Bladder 269 

Villous Cancer of the Bladder .273 

Acute Abscess of the Prostate Gland 279 

Chronic Prostatitis 281 

Chronic Prostatitis, with Hypertrophy of the Prostate Gland .... 285 

Chronic Spermatocystitis, or Seminal Vesiculitis 289 

Hemorrhage from Seminal Vesicles, with Acute Prostatitis . . . . .291 

Chronic Catarrhal Vaginitis 295 

Ulcerative Vaginitis 297 



2 URINARY ANALYSIS AND DIAGNOSIS. 

The proximal convoluted tubule originates from the capsule of Bow- 
man as a slightly narrowed, funnel-shaped neck ; and, after repeated 
convolutions in the cortex, tends downward into the medulla. Here | 
becomes narrow and represents the descending branch of Henle's loop.; 
After reaching certain depths in the medullary substance, it turns upon 
itself, producing Henle's loop, and passes again toward the surface as 
the ascending branch of the narrow tubule or of Henle's loop. It now 
widens, and, at the most peripheral part of the cortex in which there are 




CT< 



Fig. 1. — Malpighian Corpuscle. 
T, Capillary loops of the glomerulus, in connection with the afferent artery, covered fcn 
E, flat epithelia; Ca, capsule covered with flat epithelia, in communication with Co, th| 
convoluted tubule ; CL, convoluted tubule in longitudinal section; CT , convoluted tubull 
in transverse section (X 350). 

no glomeruli, again becomes a convoluted tubule — the distal convolutec 
tubule, also known as the intercalated tubule, which inosculates with 
the arched or straight collecting tubule. The latter runs down througl 
the medulla, unites with other arched tubules, becomes broader, ant 
enters the papilla as tubule of Bellini, which empties into the calyx ano 
pelvis of the kidney. 

The uriniferous tubules are lined by a single layer of epithelia, ano 
each portion has its peculiar epithelial lining. In a general way, this ii 
cuboidaJ in the convoluted tubules, flat in the narrow, and columnar ii 
the collecting tubules, although different portions of both the narrow ano 
collecting tubules are also lined by cuboidal epithelia. All tubules ar 



HISTOLOGY AND SECRETION. 




vit 

Fig. 2. — Diagram of the Kidney. 

T, Malpighian corpuscle; CT, capsule of Malpighian corpuscle; CI, proximal con- 
anft ' oluted tubule; N, narrow or looped tubule; CH, distal convoluted tubule; S, straight 
ollecting tubule in the medullary ray of the cortical substance; C, straight collecting 
ubule in the medullary substance; P, straight collecting tubule in the papilla; A, renal 
rtery; V, renal vein; AV, afferent vessel; EV , efferent vessel; B, arterial branch to the 
ortical substance; AP, arterial branch to the medullary substance; CC, capillaries of 
onvoluted tubules ; CS, capillaries of narrow tubules ; CP, capillaries of straight collect- 
ig tubules; VR, blood-vessels of the medullary substance; L, capillaries of papilla. 
he sum total of the convoluted tubules is termed the labyrinth, while the straight 
ubules, both narrow and collecting, produce the medullary rays between the labyrinths 
the cortex. 



nil 



4 URINARY ANALYSIS AND DIAGNOSIS. 

surrounded by a delicate connective tissue which carries the blood-ves- 
sels and nerves. 

The peculiarities of the cortical and medullary substances are shown 

in Figs. 3 and 4. 




Fig. 3.— Cortical Substance of the Kidney. Transverse Section. Blood- 
vessels Injected (X 500). 
C, Convoluted tubule; JV, narrow tubule; N A, ascending branch of narrow tubule : 
S, straight collecting tubule. 




N D 



"*"^r,. -:i-,m 



Fig. 4. — Medullary Substance of the Kidney. Transverse Section. Blood 
Vessels Injected (X 500). 
N, Narrow tubule; ND, descending branch of narrow tubule; S, straight collectin; 
tubule; V, blood-vessels. 



HISTOLOGY AND SECRETION. 5 

The vascular supply of the kidney is in intimate relation with the 
uriniferous tubules. The renal artery divides into a number of branches, 
known as the interlobar arteries, which, upon reaching the boundary 
zone between the cortical and medullary substance, bend sharply and 
produce the arterial arches. Each artery is accompanied by a vein, the 




Fig. 5. — Injected Blood-Vessels of the Cortical Substance of the Kidney of a 

Dog (X 100). 
Ca, Capsule; O, outer zone, devoid of Malpighian corpuscles; T, Malpighian cor- 
puscle; A, afferent vessel; E, efferent vessel; R, branch of renal artery; Co, zone of 
convoluted tubules; S, zone of straight tubules. 



veins being connected by lateral branches and producing a venous plexus. 
From the arches straight arterial branches — the interlobular arteries — 
arise, which penetrate the cortical substance, divide, and give off numer- 
ous transverse twigs — the afferent vessels of the glomerulus (see Fig. 5). 



URINARY ANALYSIS AND DIAGNOSIS. 






The afferent vessel breaks up into a number of small branches which in 
turn give rise to groups of capillaries forming the glomerulus. Large! 
capillaries, arising from the smaller, unite to form the efferent vessel, 
which leaves the glomerulus near the entrance of the afferent vessel, and [i eons 
is smaller than the latter. The entire blood supply of the glomerulus is | 
arterial. The efferent vessel soon divides freely into capillaries, for the 
supply of the cortical as well as the medullary substance. In these capil- 
laries the blood gradually becomes venous and passes into the interlobu- 
lar veins, which accompany the arteries to the boundary between the 
cortical and the medullary substance; here they enter the venous arches 
which accompany the arterial arches. 

The kidney is richly supplied with medullated and non-medullated 
nerve fibres,' which accompany the arteries and may be traced to the 
epithelia of the uriniferous tubules. 



pom 

thou 

torn 1 

I 

jinrt 



Urine, the excretion from the kidneys, is produced partly by the 
process of filtration in the glomeruli, and partly by the activity of the 
epithelia of the uriniferous tubules. In the glomeruli, not only the 
water is derived from the blood, but also certain inorganic salts, such as 
sodium chloride, and possibly a few other solids are. separated. The 
amount of the fluid filtered off depends almost entirely upon the blood 
pressure in the glomeruli. The epithelia of the uriniferous tubules con- 
stitute the true secretory structure of the kidney. 

These views, which were first promulgated by Bowman in the year' 
1842, were later corroborated by experiments of Heidenhain, who injected 
indigo- carmine into the blood of animals, and found that a blue colon 
appeared in the urine soon afterward, and that the epithelia of the con- 
voluted and ascending branch of the narrow tubules were stained blue^ 
while the Malpighian corpuscles did not show the slightest traces of the; 
stain. After section of the spinal cord, which causes lowering of the 
blood pressure in the renal glomeruli, and injection of indigo-carmine 
the epithelia of the uriniferous tubules were stained blue with this sub-* 
stance, which was also found in the lumen of the tubules, while the glo-> 
meruli were free from stain. This appears to show that under ordinary 
circumstances the indigo-carmine is eliminated by the tubular epithelia 
and that, when by diminishing the blood pressure the filtration of urine 
ceases, the substance remains in the tubules. 

In the light of our present knowledge upon this subject, it is evident 
that most of the saline constituents of the urine are the excretory prod- 
ucts of those uriniferous tubules which are richly supplied with capillar) 
blood-vessels and the epithelia of which are closely connected with the 
walls of the vessels. The thickened blood contained in these vessels re 



HISTOLOGY AND SECEETION. 7 

absorbs a portion of the liquid from the tubules and supplies the liquid 
1 in the tubules with a certain amount of its salts. The whole process is 
accomplished through the agency of the living epithelia, and is not to be 
considered a simple process of osmosis. The differences in the struct- 
ure of the epithelia in certain portions of the uriniferous tubules, and 
the striking differences in the distribution of the blood-vessels, strongly 
point toward a difference in the function of portions of the tubules, even 
though up to the present time no exact demonstration of these functions 
concerning the constituent elements of the urine has been furnished. 

Pathological conditions also prove that the renal epithelia possess im- 
portant functions. In diseases in which the function of the tubules is 
much interfered with, their epithelial lining being destroyed to a consid- 
erable degree, urea and allied products are retained in the system, and 
the phenomena of uraemia result. The urine in such cases is of a more 
watery character than normally, has a lower specific gravity, and con- 

• l tains a smaller amount of its characteristic solids. 

tl: 

tt 

1 

rii 

ii 

on 



P5 



t! 



CHAPTER II. 

GENERAL REMARKS. 

Urinary analysis, in order to be thorough and of practical value, 
must necessarily be both chemical and microscopical. Chemical exam- 
ination, although of great importance, can alone never lead to a correct 
diagnosis; only through the use of the microscope the nature of the dis- 
ease in the genito-urinary tract, as well as its exact location, can be re-' 
vealed. Every urine to be examined should be first subjected to different 
chemical tests, the extent of which will vary with the different cases, and 
then to a microscopical examination. 

In the majority of cases the simpler chemical tests alone will be re- 
quired. These must be made, first, with a view of determining the char- 
acter and amounts of the normal constituents of the urine; secondly, for 
the purpose of learning of the presence of any abnormal constituent. A 
general knowledge of the normal constituents is, therefore, necessary; 
and we must not lose sight of the fact that these may vary to a consider- 
able degree, even in perfect health, partly from diet, and partly from 
conditions of rest or activity. An increased or diminished amount of 
any ingredient does not necessarily mean a pathological condition, al- 
though when this increase or diminution lasts for a long time a diseased 
condition becomes certain. 

In selecting a specimen for examination, it is essential for accurate 
diagnosis to obtain the total amount of urine passed during the whole 
twenty-four hours, or to have the patient collect the entire amount, 
measure it carefully, note the exact quantity, and send from four to eight 
ounces of the mixed urine. In collecting the twenty-four hours' amount, 
mistakes are frequently made. The procedure should be the following: 
A certain time — for instance, eight o'clock in the morning — is selected 
for starting the collection of urine; the bladder should be emptied at this 
lime mikI the urine voided thrown away; every drop of urine subse- 
quently voided is carefully collected, the patient being instructed to void 
and collect the urine before each movement of the bowels, the last amount 
taken being at eight o'clock the following morning. The amount of 
urine is now measured and noted. The urine may be kept in clean bot- 
fcles of :inv size, although a bottle holding about half a gallon is preferable. 

The reasons for collecting the twenty-four hours' amount are various; 

8 



GENERAL REMARKS. 9 

not only is the total quantity voided important in diagnosing different 
affections, but the proportions of the normal as well as of the pathological 
ingredients vary considerably at different hours of the day and night, so 
that the exact amounts of these ingredients cannot be determined when 
specimens from single urinations are examined. In cases in which the 
quantitative estimation of urea and solids generally is not essential, or in 
which the total twenty-four hours' amount cannot be obtained, it is best 
to obtain the specimen during the day, a few hours after meals, or in the 
evening. The urine first voided in the morning, although usually the 
most concentrated, is not the best for examination, since different patho- 
logical ingredients, such as albumin and even sugar, may be absent in the 
morning and yet be present in varying amounts at other times. If any 
doubt remains as to the exact condition in such cases, two samples, 
passed at different times, must be tested. 

Care should be taken that the bottles in which the urine is kept are 
scrupulously clean and well corked, and that the urine be obtained in as 
fresh a condition as possible. When the whole twenty-four hours' urine 
is collected, the bottle should be kept in a cool place and the urine poured 
into it as soon as possible after being voided. Even then, secondary 
changes cannot always be guarded against. In cold weather such changes 
will usually not take place for many hours, but in warm weather decom- 
position is apt to set in at the end of a few hours, and bacteria develop 
in A^arying numbers. When not absolutely necessary, it is not advisable 
to add any preservatives to the urine until after the chemical tests have 
been made. Extraneous objects can easily find their way into the urine 
when care is not exercised as to cleanliness, and these not infrequently 
lead to confusion in examination. 

When urine is received for examination, it should be set aside for at 
least six hours, that a sediment may be deposited, unless it is preferred 
to use the centrifuge, when examination can proceed at once. In the 
former case the upper part of the urine is used for chemical tests, and the 
sediment for microscopical examination; while in the latter a small 
amount is used for the centrifugal apparatus, and chemical examination 
can at once be conducted with the remainder. 

After determining the amount of urine voided in twenty-four hours, 
we must note the color, odor, transparency, and reaction, and carefully 
determine the specific gravity. The approximate amount of urea voided 
in twenty-four hours should then be estimated by chemical tests, and 
the total amount of solids voided, determined. As urea, the chief organic 
constituent of urine, forms approximately forty to fifty per cent of all 
the solid ingredients, the specific gravity of the specimen will frequently 
give an idea of its increase or diminution in a given case. That errors 



10 UBINABT ANALYSIS AND DIAGNOSIS. 

are liable to result from such an estimation is evident, and wherever pos- 
sible a ureometer should be used. 

The next step should always be the determination of the presence or 
absence of albumin, as well as its approximate amount if present, while 
further chemical tests will vary with each individual case. Whenever 
ill.' specific gravity is above normal, or any clinical symptoms lead to a 
suspicion of the presence of sugar, even at a low specific gravity, tests 
for sugar must be resorted to. Should it be desired to know the approx- 
imate amounts of uric acid, chlorides, sulphates, and phosphates present, 
though this is not always essential for the diagnosis, the simpler tests for 
these ingredients will, as a rule, be all that are required. 

Before resorting to microscopical examination, the nature of the sedi- 
ment, whether it is present in small or large amount, its color, and its 
general character should be noted; and then all the elements found un- 
der the microscope, as well as their comparative numbers, should be 
carefully observed. It will always be safest to examine a number of 
drops before coining to a conclusion and determining upon the diagnosis. 



PART FIRST. 

CHEMICAL EXAMINATION 



PART FIRST. 

CHEMICAL EXAMINATION 



CHAPTER III. 

GENERAL PHYSICAL AND CHEMICAL PROPERTIES. 

Normal urine is a yellowish, transparent liquid, of a peculiar odor, 
and always of an acid or faintly acid reaction, when the entire twenty- 
four hours' amount from a person on a mixed diet is tested. This reac- 
tion is not due to free acid, but to acid sodium phosphate (monosodium 
phosphate of the formula NaH 2 P0 4 ), which turns blue litmus paper red. 
The degree of acidity of the urine varies at different times of the day. 
After ingestion of large amounts of vegetables and alkaline waters, the 
reaction may temporarily become alkaline. 

For all clinical purposes the determination of the reaction by means 
of litmus paper is sufficient; blue litmus paper turning red in acid urine, 
and red litmus paper turning blue in alkaline urine. A rough idea of the 
degree of acidity or alkalinity can be obtained by the intensity of the 
change in color, and may be noted as " faintly acid or alkaline," "acid 
or alkaline/' and "highly acid or alkaline." Urine is rarely neutral, but 
it occasionally gives both reactions with litmus paper — that is, turns 
blue litmus paper red and red litmus paper blue; and this reaction is 
known as amphoteric. It is due to the presence in variable proportions 
of both acid monosodium phosphate (NaH 2 P0 4 ) and alkaline disodium 
phosphate (Na 2 HP0 4 ) . 

The color of normal urine is yellowish or amber, although the tints 
even in health may vary considerably and generally depend upon the 
degree of concentration and the pigments. The reaction also has an in- 
fluence upon the color, and highly acid urine frequently becomes darker 
upon standing, due to the oxidation of chromogens. 

According to Vogel, the following color tints may be distinguished: 

13 



1 [ URINARY ANALYSIS AND DIAGNOSIS. 

1. Pale yellow ) 

2. Light yellow >■ Yellow urines 

3. Yellow ) 

4. Reddish-yellow ) 

5. Yellowish-red Y Reddish urines 

6. Red ) 

7. Brownish-red ) 

8. Reddish-brown V Brown or dark urines 

9. Brownish-black ) 

Palo or light yellow urines are rarely highly acid, but usually slightly 
acid, amphoteric, or alkaline, and denote dilution and an increase in the 
amount of urine. Reddish-yellow to brownish-red urines are usually rich 
in solid constituents, contain considerable urea, and are not highly acid. 
Abnormally dark urines may be due to accidental pigments or medicines. 
A dark yellow or reddish-yellow color may be due to rhubarb, senna, 
santonin, or considerable salicylic acid; a red color, to antipyrin, anti- 
febrin, sulfonal, or trional; a brownish-black color, to resorcin, tannin, 
carbolic acid, guaiacol, or thymol; a greenish-black color, to salol or 
pyrogallol; and a blue or greenish-blue color, to methylene blue. 

The average amount of urine passed by a healthy adult in twenty-four 
hours is about 1,500 cubic centimetres, or 50 ounces, although it varies 
between 1,200 and 1,800 c.c, women passing somewhat smaller quanti- 
ties than men. The specific gravity varies from 1.015 to 1.025, the ave- 
rage being 1.020. 

The amount of urine voided is greatly influenced by different factors. 
It is greater the more liquid is taken into the body, and as the amount of 
solids, which determines the specific gravity, usually remains about the 
same in health, it follows that the specific gravity will be lower the greater 
the quantity voided. The amount of the perspiratory excretion has a 
great bearing upon the quantity of the urine, and in cold weather, when 
the perspiration is lessened, the urine increases in amount. Different 
articles of diet, such as tea and coffee, undoubtedly stimulate the excre- 
tion of urine. Nervous excitement, anxiety, and hard mental work have 
the same effect. Bodily exercise, increasing perspiration, lessens the 
amount of urine, and therefore renders it more concentrated. The specific 
gravity of urine voided at different hours of the day may, therefore, vary 
to a great degree, sometimes being as low as 1.002 or 1.003, and at other 
times 1.030, without indicating, in any manner, a pathological condition. 

Consistency and Odor.— Normal urine is of a watery consistency and 
loams if shaken, though the foam soon disappears when at rest. It has 
a peculiar, characteristic odor, which is more or less pronounced accord- 
ing to the degree of concentration, and is spoken of as aromatic or urin- 
ous. If the urine has become alkaline, it acquires a disagreeable, repul- 



PHYSICAL AND CHEMICAL PROPERTIES. 15 

sive, so-called ammoniacal odor, which is due to the presence of bacterial 
decomposition products (probably ammonia and phenols). After inges- 
tion of certain articles of diet and after taking different medicines, the 
urine emits a more or less characteristic odor. The peculiar odor after 
eating asparagus is said to be due to methylmercaptan. After the ad- 
ministration of oil of turpentine an odor not unlike violets is produced. 
The odor of copaiba, cubebs, and oil of sandalwood is communicated to 
the urine when these drugs are taken internally. An odor, at first not 
unlike sweet-brier, but soon becoming very offensive, is present when the 
urine contains cystin. 

The solid constituents of normal urine are partly inorganic and partly 
organic. The total amount of solids voided with the urine in twenty-four 
hours is between 60 and 70 gm. The following table of Hammarsten 
gives the average amounts of solids voided by a healthy adult: 

1. Inorganic constituents less than 27.0 gm. 

Hydrochloric acid, HC1 about 9.35* 

Sulphuric acid, H 2 S0 4 2.50 

Phosphoric acid, P 2 5 2.50 

Nitric acid, HN0 3 less than 0.10 

Sodium oxide, Na 2 7.90f 

Potassium oxide, K 2 3.00 

Ammonia, NH 3 0.70 

Calcium oxide, CaO 0.30 

Magnesium oxide, MgO 0.50 

Iron, Fe . . ." less than 0.01 

2. Organic constituents . 35.0 gm. 

Urea about 30.0 

Uric acid 0.7 

Creatinin 1.0 

Hippuric acid 0.7 

Other organic constituents a total of 2.6 

These consist of purin bodies, oxalic, oxaluric, lactic, carbamic, and 
succinic acids, carbohydrates, glycerophosphoric acid, ethereal sulphates 
of phenol, cresol, pyrocatechin, indoxyl and skatoxyl, pigments, chromo- 
gens, ferments, and a few other non-important substances. 

The urinary pigments or coloring matters found in urine are urochrome, 
which gives the yellow color to the urine; hsematoporphyrin, urohsem- 
atin, uroerythrin, uroindican, and urobilin. The latter is not, as a rule, 
found in freshly voided urine, but is always found after standing; hence 
it is present as a chromogen, named urobilinogen. All of these coloring 
matters are not necessarily present in every urine, the three important 
ones being urochrome, hsematoporphyrin, and urobilin. 

*As sodium chloride, 15 gm. fAs sodium chloride, 15 gm. 



16 URINARY ANALYSIS AND DIAGNOSIS. 

The gaseous constituents are carbonic acid, nitrogen, and oxygen, the 
latter in very small amount only. 

( 'hanges upon Standing.— Normal, freshly voided urine is always per- 
fect lv clear, but if left at rest for a few hours a cloudy sediment, more or 
less pronounced, forms, and is usually more marked in the urine of fe- 
males. This sediment, which at first usually floats in the centre of the 
urine and gradually settles at the bottom, is known as nubecula, and 
disappears entirely upon shaking. It consists of mucus, with a few flat 
epithelia from the bladder, and, in the urine of females, from the vagina. 
In addition to these features, epidermal scales from the prepuce and 
nvniplue will always be found, and spermatozoa may also be present. 
At the time of menstruation the urine is red and contains numerous red 
blood corpuscles. A normal acid urine may, after a few hours, precipi- 
tate some amorphous urates, then a few uric-acid crystals, and occasion- 
ally a small number of calcium-oxalate crystals. 

After the urine has remained standing for one or more days, bacteria 
develop, their number and rapidity of development depending upon the 
temperature. In warm weather they may appear in the course of a few 
hours. In highly acid urine conidia and mycelia not infrequently form, 
though cocci and bacilli may also be found. Saccharomycetes or yeast 
fungi may similarly develop in acid urine; these are most commonly, 
though not exclusively, seen in urine containing sugar. In alkaline urine 
fission fungi — both cocci and bacilli — are seen in large numbers. When 
ammoniacal decomposition of the urine sets in, the urea is gradually 
transformed into ammonium carbonate through the activity of the 
micro-organisms. Such a urine becomes turbid or opaque from the 
presence of the fission fungi and precipitated phosphates. The deposit 
of amorphous urates now becomes transformed into ammonium urate, 
while uric-acid and calcium-oxalate crystals disappear, and characteristic 
crystals of triple phosphates develop. 

Under Pathological Conditions the urine may be passed as a cloudy 
liquid of varying consistency. The highest degree of viscidity is usually 
found in chronic cystitis, when the urine, being strongly alkaline and 
decomposing in the bladder, appears as a viscid, stringy, muco-purulent 
mass, with a repulsive ammoniacal odor; it contains a varying number 
of bacteria and a large amount of phosphates. In suppurative condi- 
tions the urine often has a peculiarly offensive, putrid odor. In severe 
cases of diabetes a sweet or fruity odor of acetone is often imparted to 
the urine, while a fecal odor is present in cases of fistula communicating 
with the intestines. 

The color of the urine will be greatly changed by an increase or de- 
crease of the normal coloring matters or the abnormal presence of biliary 



PHYSICAL AND CHEMICAL PROPERTIES. 17 

matter. Biliary pigments color the urine reddish-brown, brown, or 
greenish, and give to it a greenish-yellow foam. When the urine is 
mixed with blood it will be more or less dark colored. In febrile condi- 
tions it is, as a rule, highly acid in reaction, and has a reddish or reddish- 
brown color, partly due to an excessive amount of urates, and partly to 
the presence of uroerythrin. The same may be the case in many slight 
disturbances of the system. In the rare cases of chyluria the urine is 
milky in character. 

The sediment may be considerably increased. An increased amount 
of uric acid gives a red, so-called brick-dust sediment, which also adheres 
to the sides of the vessel, while an excess of amorphous urates gives a 
heavy, turbid, so-called clay-water sediment. The presence of inflam- 
matory products or phosphates may produce a flaky or granular sedi- 
ment, and the presence of filaments or threads from the urethra or pros- 
tate gland in cases of urethritis and prostatitis a flocculent sediment. 

The amount of urine varies considerably in many pathological condi- 
tions. Increased quantity of urine is known as polyuria, diminished 
quantity as oliguria, partial or complete suppression as anuria. The 
urine is increased in amount in most cases of diabetes mellitus, and its 
specific gravity is generally high — 1.030, 1.040, or more — although the 
color is frequently pale, even straw yellow. In some cases of diabetes, 
however, the specific gravity may not only be normal, but below normal 
— 1.015, 1.012, or less — and still a large amount of sugar may be present. 
The quantity of urine is also considerably increased in diabetes insipidus, 
in hysteria, convulsions, convalescence from different acute inflammatory 
diseases, hypertrophy of the heart, and chronic nephritis, especially cir- 
rhosis of the kidney. Patients suffering with cirrhosis constantly void 
large quantities of pale, at times almost colorless urine, with greatly de- 
creased solid constituents and a specific gravity frequently below 1.010. 

The amount of urine is decreased in acute inflammations of the kid- 
ney, as well as in acute inflammatory conditions of the other organs and 
acute fevers. The urine may be more or less completely suppressed in 
uraemia, in the last stages of cholera and yellow fever, in rapidly progres- 
sive forms of ana?mia, in shock due to internal injuries, after catheteriza- 
tion, and in obstructive diseases of the urinary passages. In persons 
suffering from nephritis it may be suppressed after the administration of 
anaesthetics. 

Determination of Specific Gravity. — The simplest method of ascer- 
taining the specific gravity is by means of the aerometer, urometer, or 
urinometer (see Fig. 6), which, if carefully constructed, will be sufficiently 
accurate for all practical purposes. If tested with distilled water, such a 
urinometer will sink to the 1.000 mark at the average temperature of the 



18 



URINARY ANALYSIS AND DIAGNOSIS. 



4, 




room. The specific gravity of a specimen should be taken only after it 
is cooled; otherwise errors will result. The glass cylinder supplied with 
the instrument should be fluted, so that the latter will not cling to the 
side of the glass. The test is made as follows: Fill the cylinder four- 
fifths full of urine, removing the froth, if any is present, with filtering 
paper. Place the urinometer in the urine, being careful not to allow it 
to come in contact with the walls of the vessel. Bring the eye on a level 
with the surface of the urine, and read the corresponding division of the 
urinometer, but not the upper rim of the fluid; raised 
a little by capillary attraction. Touch the stem, 
causing the urinometer to sink slightly in the fluid, 
and, after it has come to rest, read again. 

If the amount of urine is small, dilute the speci- 
men with one, two, or even three volumes of water; 
test as before directed, and multiply the number 
A of the division mark by the number of volumes used 
in the process of dilution. For example, if two vol- 
umes of water have been added to one volume of 
urine, thus making three volumes in all, and the urin- 
ometer stands at 1.006, the real specific gravity of 
the original urine is 1.018. The solid materials 
upon which the specific gravity depends, which were 
dissolved in one volume, are, after dilution, dissolved in three volumes, 
and the specific gravity is therefore only one-third of the original. 

As indicated above, the temperature is important, and the specific 
gravity should never be taken when the urine is freshly voided. The 
urinometers are graduated at a temperature of about 15.5° to 17.5° C. (60° 
to 63.5° F.). If the urine is warmer than this temperature, one- third 
of a urinometer degree should be added for each degree of urine temper- 
ature; if colder, one-third of a urinometer degree should be subtracted 
for each degree of urine temperature. A temperature scale is found on 
many urinometers, or a thermometer is supplied with the instrument.* 
More accurate methods for determining the specific gravity are the 
pyknometer and the Mohr-Westphal balance. The latter is useful only 
in more exact work. With the pyknometer exact estimations can also 
be obtained. Many different types of this instrument are used, but a 
simple one is shown in Fig. 7. This is a flask with a long neck that is 
drawn out in one place; at the narrowest point is a mark; the flask is 
closed with a ground-glass stopper. The flask is first filled with distilled 
water to the mark and weighed; it is then filled with the filtered urine to 

* S(|uil>l)'s urinometers, which are used considerably in this country, are stan- 
dardized at 22.5° C. or 72.5° F., a more convenient temperature for clinical work. 



Fig. 6. — Urinometer. 



PHYSICAL AND CHEMICAL PROPERTIES. 



19 




F]G. 



7. — Ptkno- 

METER. 



the mark and weighed again. The weight of the urine divided by the 
weight of the water gives the specific gravity. It is very important that 
the temperature of the water and that of the urine 
should be exactly alike when the pyknometer is filled 
and when it is weighed * 

Determination of Solids. — To determine the amount 
of solids present in the urine voided during twenty-four 
hours, for practical work, the exact quantity passed 
during this time, as well as its specific gravity, must 
be known. The specific gravity is directly dependent 
upon the amount of solids in solution, a diminution of the 
isolids giving a lower, an increase a higher, specific gravity. 

For clinical purposes the amount of total solids 
voided can be approximately determined by multiply- 
ing the last two figures of the specific gravity by the 
coefficient of Haeser, which is 2.33; this gives the num- 
ber of grams of solid matter in 1,000 c.c. of urine. This 
number, multiplied by the number of cubic centimetres passed in 
twenty-four hours and divided by 1,000, will give the amount of solid 
3onstituents eliminated during that time. 

Suppose, for example, 1,500 c.c. of urine were passed in twenty-four 
lours, of a specific gravity of 1.020. To estimate the amount of solids, 
nultiply the last two figures, 20, by the coefficient, 2.33, and by 1,500, 
ind divide by 1,000, thus: 

20 X 2.33 X 1,500 

- = 69.90 gm. 

1,000 b 

3r, 20 X 2.33 X 1.5 = 69.90. Again, if 1,250 c.c. of urine were passed, of 
specific gravity of 1.018: 18 X 2.33 X 1.25 = 52.425 gm., the total amount 
pf solids voided in twenty-four hours. 

Valuable conclusions as to the amount of solids may thus be obtained 
rom the specific gravity in a very short time. In diabetes, for instance, 
he quantity of urine voided being large and of a high specific gravity, 
he amount of solids is considerably increased; in inflammations of the 
ddney, on the other hand, where the quantity of urine is decreased and 
he specific gravity is low, the amount of solids is diminished. No de- 
motions, however, can be drawn from the amount of total solids as to 
-he amount of any particular solid, especially urea. Although urea con- 
ititutes from forty to fifty per cent of all the solids excreted in healthy in- 
lividuals, in pathological conditions the proportions of urea and the 
)ther solid constituents often vary to a considerable degree. 

*Croftan: " Clinical Urinology, 1904." 



CHAPTER IV. 

NORMAL CONSTITUENTS. 

A. ORGANIC. 

Urea.— Urea or carbamide (CON 2 H 4 ) is the chief organic constitu- 
ent of urine and the most important nitrogenous waste product found in 
urine. The greater portion of nitrogen taken into the system as food is 
excreted by the kidneys in the form of urea, which substance represents 
between eighty-five and ninety per cent of the total nitrogen of the urine, 
the other ten to fifteen per cent being represented mostly by uric acid, 
creatinm, hippuric acid, ammonia, xanthin, and allantoin. The amount 
of urea excreted varies greatly under different physiological conditions, 
ranging between 20 and 35 or 40 gm., or approximately between 310 and 
620 grains in twenty-four hours; this represents from forty to fifty per 
cenl or more of all the solid ingredients voided. As urea is the most 
abundant solid of urine, it influences the specific gravity most, which 
latter will therefore give an approximate idea of an increase or decrease 
of urea. A specimen of normal urine, with a specific gravity of 1.020 
and voided in a quantity of about fifty ounces (1,500 c.c), will contain 
about 450 or 500 grains of urea (28 to 31 gm.), or 9 to 10 grains to the 
ounce, or about two per cent. 

Normally the amount of urea excreted varies greatly with the diet; 
it is most abundant after an exclusive meat diet, less abundant after a 
mixed, and least abundant after a strictly vegetable diet. It is increased I 
after muscular exercise and mental activity. Pathologically it is in- 
creased in acute fevers, owing to increased tissue metabolism, and in 
diabetes, in the latter condition sometimes to a considerable degree. It , 
is decreased in diseases of the liver— the liver being the chief seat of the 
formation of urea— in diseases of the kidney, and in chronic affections 
impairing the vitality of the patient. 

Urea is frequently decreased in normal pregnancy. It is a common, 
and undoubtedly commendable practice to examine the urine for urea at 
stated intervals during pregnancy. Unfortunately, the many different 
factors which should be taken into account, such as diet, exercise, and I 
the condition of the gastro-intestinal tract, are frequently overlooked,! 
and unnecessary anxiety is caused by a continued diminution in the! 

20 



JSOBMAL CONSTITUENTS. 



21 



amount of urea excreted. In these cases too much significance should 
not be attached to the decreased amount of urea alone, but all the im- 
portant chemical tests, as well as thorough microscopical examination, 
must be resorted to before alarming the patient or her relatives. 

Urea is always held in solution and can never be found under the 
microscope without chemical means. It crystallizes in the form of color- 




Fig. 8 



— Crystals of Urea (Upper Half) and Nitrate of Urea (Lower 
Half) (X 200). 



less quadrilateral plates or prisms, and in needles of varying sizes. It is 
readily soluble in water and alcohol, but is insoluble in ether. Urea can 
easily be detected as nitrate of urea by placing a few drops of urine upon 



22 



UEINABY ANALYSIS AND DIAGNOSIS. 



a -lass slide, adding a drop of nitric acid, warming the slide carefully, 
and placing it aside to crystallize. Under the microscope more or less 
regular rhombic or hexagonal plates, either single or overlapping each 
other, may now be found. These plates have a little color and are per- 




Fig. 9. — Doremus' Ureometer. 

fectly characteristic (see Fig. .8). With oxalic acid it forms oxalate of 
urea, in the form of flat or prismatic crystals. 

Quantitative Tests. — The quantitative tests for determining the exact 
amount of urea present in the urine are numerous, but more or less 
complicated. The simplest is the hypobromite method, the principle of 
which depends upon the fact that, when urea comes in contact with an 
alkaline sodium-hypobromite solution, it is decomposed into nitrogen, 
carbon dioxide, and water, according to the following equation: 

CO(NH 2 ) 2 +3NaBrO=3NaBr+2H 2 0+CG 2 +N 2 . 

The carbon dioxide which develops is absorbed by the sodium hydroxide, 
while from the volume of nitrogen liberated the amount of urea can be 
calculated. 

The quickest way of carrying out this method is by means of Dore- 
mus' ureometer. The hypobromite solution necessa^ for this test does 
not keep well, and it is therefore best to keep the bromine and the caustic- 
soda solution separate. Have on hand a solution of sodium hydrate — 
100 gm. of caustic soda to 250 c.c. of water (or four ounces to ten of 
water)— and the bromine, in separate bottles. To prepare the solution 



NORMAL CONSTITUENTS. 



23 



for immediate use, take 10 c.c. of the sodium-hydrate solution and add 
1 c.c. of bromine; mix thoroughly, dilute with equal parts of water, and 
the solution is then ready for use. A glass graduate, of a capacity of 25 
c.c, will be found the most convenient for this purpose. 

Doremus' apparatus (see Fig. 9) consists of a bulb and graduated 
tube and a small curved nipple-pipette to hold 1 c.c. of urine. The bulb 
of the ureometer is filled with the hypobromite solution, and by inclining 
the tube the long arm is filled to the bend in the bulb. By means of the 
nipple-pipette 1 c.c. of urine is drawn up, the pipette passed through the 
bulb of the ureometer as far as it will go in the bend, and the nipple com- 
pressed gently and steadily. The urea instantly decomposes, and the 
bubbles of nitrogen rise in the long arm of the instrument, while the dis- 
placed liquid flows into the bulb. The decomposition of urea is complete 
in ten or fifteen minutes, and the graduation on the tube indicates the 
quantity of urea in i c.c. of urine. Two forms of the instrument are 
furnished— one graduated to read fractions of a gram to the cubic centi- 
metre of urine, the range being from 0.01 to 0.03 gm. ; to obtain the per- 
centage, multiply the number of divisions on the 
tube by 100; thus, 0.02 gm. to the cubic centi- 
metre is two per cent of urea. The other form 
of the instrument is graduated to show the 
number of grains of urea per fiuidounce of 
urine. 

Hinds' modification of the Doremus appa- 
ratus (see Fig. 10) is more convenient and more 
accurate than the original form, as it obviates 
the use of a pipette. The amount of urine is 
measured more exactly, being introduced into 
the graduated small tube and the flow con- 
trolled by the stopcock. 

For all clinical purposes the above method 
is perfectly sufficient and no other is required. 
For accurate scientific work, however, more 
elaborate methods are necessary, and of these 

the method of Morner and Sjoqvist gives the most accurate results. If 
urine is treated with a mixture of barium chloride and barium hydrate 
and then allowed to stand under alcohol-ether for twenty-four hours, 
all the nitrogenous constituents of the urine are precipitated, while the 
urea is dissolved in the alcohol-ether. The urea solution is filtered off and 
the nitrogen content of the filtrate determined by Kjeldahl's nitrogen 
method, which consists in converting all the nitrogenous constituents 
of the urine into ammonia by boiling the urine with concentrated sul- 




Fig. 10. — Hinds' Modifica- 
tion of Doremus' Ure- 
ometer. 



24 I RINAEY ANALYSIS AND DIAGNOSIS. 

phuric acid. The ammonia combines with the sulphuric acid to am- 
monium sulphate; caustic soda is then added to liberate ammonia gas, 
which is distilled off into a known amount of sulphuric acid. The 
amount of uncombined sulphuric acid is next determined and subtracted ] 
from the known total. The difference equals the amount neutralized 
by ammonia, and from this factor the amount of urea is calculated. 
The method is too complicated for clinical work. 

Uric Acid.— Uric acid (C 5 H 4 N 4 3 ), like urea, is a nitrogenous prod- 
uct, although it is normally found in urine in small amount only, 0.4 to 
\:2 gm. (7 to 20 grains) being the amount usually voided in twenty-four 
hours; the average is 0.7 gm. Like urea, the amount excreted is depend- 
ent upon the diet, and under normal conditions is in direct proportion to 
the amount of urea excreted; the proportion is 1 of uric acid to 45 of 
urea. 

Trie acid is probably formed chiefly in the liver and to a small degree 
in the spleen, but not in the kidneys, being only excreted by the kidneys. 
Recent researches tend to show that it is derived from the nucleins, the 
chief chemical constituent of all cell nuclei ; foods rich in nucleins give rise 
to the formation of uric acid. Its excretion is increased by a diet rich 
in protein matter, especially with diminished exercise or sedentary 
habits; in acute fevers; diseases of the lungs and heart accompanied by 
dyspnoea; abdominal tumors which impede respiration; rheumatism; 
in severe blood diseases, especially leukaemia, in which there is a disin- 
tegration of the nuclei of the blood corpuscles. Its increase in gout has 
been rendered doubtful by recent investigations, as it has been found 
that such an increase does not always take place. After the adminis- 
tration of certain drugs, such as salicylates, lithium, and alkaline citrates, 
the elimination may also be increased. Uric acid is diminished by a 
vegetable diet; in chronic kidney diseases and other diseases in which 
the amount of urea is decreased; after the administration of different 
drugs, such as quinine, antipyrin, caffeine, iron, and lead. 

Pure uric acid is a white, odorless substance, feebly soluble in water, 
insoluble in alcohol and ether, readily soluble in glycerin and alkalies. 
It is not acid in reaction when tested with litmus paper. It crystallizes 
in urine in many different forms, almost invariably of a yellow or yellow- 
ish-red color; the difference in its appearance under the microscope is 
due to the degree of acidity of the urine, the concentration, the amount 
of pigments, the temperature, and the rapidity of the process of crystal- 
lization. 

1 rider ordinary circumstances uric acid does not appear in the urine 
in a free condition, but always in combination with bases, such as sodium 
and ammonium, in the form of urates; of these bases, some are acid, 



NORMAL CONSTITUENTS. 25 

others neutral. When the urine is concentrated from want of a solvent, 
or when poor in mineral salts which also act as solvents, or when pig- 
ments are deficient, precipitation occurs promptly upon cooling of the 
urine, and this also takes place when the urine is highly acid; the acidity 
is quickly neutralized by the bases of the urates, thereby liberating the 
acid. The mixed precipitate in the urine is always colored by uroery- 
fehrin; the free acid most, the ammonium urate about as much, the 
sodium urate less. The sodium urate occurs in characteristic granular 
masses, having the appearance of moss; the ammonium urate as globu- 
lar formations, at times with variously sized spicules. For the reasons 
stated above, the amount of uric acid in the urine should not be consid- 
ered excessive from the fact of a deposit forming upon cooling, as such a 
deposit may occur when the amount is small, and a true increase can be 
detected only by quantitative tests. 

The detection of uric acid is easy with the aid of the microscope, 
owing to the characteristic lozenge-shaped, rhomboidal, wedge- or whet- 
stone-shaped, barrel-shaped, and comb-shaped, yellowish crystals. The 
urates can also be easily distinguished under the microscope. 

A simple test is the murexide test: A small portion of the sediment, 
or the residue after evaporation, is placed on a porcelain dish, a few drops 
of a strong solution of nitric acid are added, and the solution is carefully 
warmed. When dry, a few drops of ammonia are added, and a beauti- 
ful purple color at once appears, which soon spreads over the dish, and 
changes into violet upon the addition of caustic potash. The color dis- 
appears upon warming. 

In this test alloxan is formed by the addition of nitric acid to uric 
acid or urates, and, by continuing the addition of nitric acid, alloxantin 
forms; this combines with ammonia to form acid ammonium purpurate, 
C 6 H 6 N 6 O fi , also called murexide. 

For a quantitative estimation of uric acid the method of Heintz can 
be used: To 200 c.c. of filtered urine free from albumin add 10 c.c. of 
concentrated hydrochloric acid ; allow to stand for twenty-four to thirty- 
six hours in a cool place; collect the precipitated uric-acid crystals on a 
previously weighed filter and wash in cold distilled water. Dry the filter 
and uric-acid crystals in a desiccator and weigh. By subtracting the 
weight of the filter, the weight of the uric acid in 200 c.c. of urine is ob- 
tained. 

Purin Bodies. — The term purin bodies, or alloxuric bases, is a collec- 
tive name used for a group of bodies, which are derived from nucleins and 
found in urine. To this group belong uric acid, xanthin, methylxanthin, 
heteroxanthin, hypoxanthin, paraxanthin, adenin, guanin, epiguanin, and 
carnin. The most important of these substances next to uric acid is 






26 VBINAEY ANALYSIS AND DIAGNOSIS. 

xanthin. With the exception of uric acid, all its members are basic. 
The relation between these bodies is a close one, and the differences be- 
tween them but small. All originate in the theoretical purin " nucleus, I 
of the formula C 5 N 4 , which yields purin by the addition of four atoms of 
H=C 5 N 4 H 4 . Purin plus one atom 0=hypoxanthin, plus 2 = xanthin, 
plus =uric acid, which is therefore best named tri-oxy-purin. If the 
amido group (NH 2 ) replaces one H in purin, amidopurin or adenin results 
and this body plus 0=guanin. 

There are two varieties of purin bodies in the urine; the one variety, 
known as "exogenous," is derived from the food and varies according to 
the character and amount of food taken, while the other variety, known 
as "endogenous," is derived from the decomposition of the nucleins of 
the tissue cells. These bases are found in the urine in minute amount 
only. Pathologically they are increased in nephritis, leukaemia, and acute 
yellow atrophy of the liver. 

Xanthin, the most important substance of this group, is chemically 
closely allied to uric acid, containing one atom less of oxygen (C 5 H 4 N 4 2 ) 
than uric acid. It crystallizes in the form of small, colorless, lozenge- 
shaped crystals or hexagonal plates, and differs from uric acid by its solu- 
bility in ammonia and hydrochloric acid as well as by heat. After the 
addition of acetic acid under the cover glass the crystals retain their form. 
Creatinin. — Creatinin (C 4 H 7 N 3 0) is a normal constituent of urine, 
being excreted in small amount, from 0.6 to 1.2 gm. in twenty-four hours. 
It, as well as creatin (C 4 H g N 3 2 ), which is occasionally found in normal 
urine, is derived from muscle tissue of the body and from meat taken as 
food, so that its amount is largely dependent upon the diet. Muscular 
activity increases the excretion of creatinin. Pathologically it is in- 
creased in acute diseases, such as typhoid fever and pneumonia, also in 
diabetes, and is diminished in conditions of wasting; 

The simplest test is Jaffe's method, which consists in treating the urine 
with a few drops of a ten per cent picric-acid and a ten per cent sodium- 
hydrate solution; if appreciable quantities of creatinin are present, the 
liquid at once turns red, which color remains for some time. 

Hippuric Acid. — Hippuric acid (C g H 9 N0 3 ), normally present in urine 
in small amounts only, is increased after the ingestion of different fruits, 
such as cranberries, plums, and prunes, as well as after the administration 
of different drugs, such as benzoic acid, salicylic acid, cinnamic acid, and 
oil of bitter almonds. Meat diet diminishes its excretion, and it is quite 
abundant in the urine of herbivorous, absent in that of carnivorous, ani- 
mals. Pathologically it is increased in intestinal putrefaction and in 
fevers, but its clinical significance is small. It is formed by a union of 
benzoic acid and glycocoll in the kidney and intestines. 



NORMAL CONSTITUENTS. 27 

Hippuric acid may be detected by boiling the urine with concentrated 
nitric acid and evaporating to dryness. The residue heated in the test 
tube gives the odor of bitter almonds, due to nitrobenzol. 

Ethereal Sulphates. — The important substances of this group are 
phenol, cresol, pyrocatechin, indol, and skatol. These bodies, as a rule, 
appear in the urine as the sodium or potassium salts of the ethereal sul- 
phates. Indol and skatol are not eliminated as indol- or skatol-sulphuric 
acid, but undergo preliminary oxidation to indoxyl and skatoxyl, appear- 
ing in the urine as the sodium or potassium salts of indoxyl-sulphuric 
acid (indican) and of skatoxyl-sulphuric acid. The ethereal sulphates 
are products of decomposition, and the amount normally excreted in the 
urine varies with the extent of putrefaction in the intestines, as well as 
according to the character of the food. Their proportion to that of the 
total sulphates of the urine is about one to ten. They are increased 
whenever putrefactive processes exist in any part of the body, such as 
putrid pus cavities and gangrenous tissues; their amount is proportional 
to the severity of the putrefaction, being increased by the retention and 
diminished by the discharge of putrid matter. They are also increased 
after the use of certain drugs, such as carbolic acid and lysol, internally 
or externally. 

Phenol and cresol may be detected in the urine by adding strong nitric 
acid and boiling, when an odor of bitter almonds will develop. After 
cooling, add bromine water; a yellow crystalline precipitate of tribrom- 
phenol appears upon standing. If a portion of the original test is ren- 
dered strongly alkaline by the addition of sodium hydrate, an orange-red 
color is observed, due to the formation of sodium nitro-phenol. 

Coloring Matters. — Normal urine contains a number of coloring mat- 
ters as well as so-called chromogens, which, though colorless, readily be- 
come colored by oxidation. 

Urochrome is the yellow pigment which gives the normal amber color 
to the urine. It can be isolated as a brown, easily soluble powder, giving 
yellow solutions in water and alcohol. It is precipitated by different 
acids. 

Hcematoporphyrin is present in minute quantities in normal urine ; its 
exact source and mode of formation are unknown. It is increased in 
Addison's disease, rheumatism and gout, lead-poisoning, and paroxysmal 
hemoglobinuria, also after prolonged use of sulphonal and trional or in 
acute poisoning with these drugs. Urine containing larger quantities of 
hsematoporphyrin has a dark wine-red, bluish-red, or even almost black 
color. 

Uroerythrin, the pigment that gives the pink color to urate deposits, 
is of no practical importance, while urohcematin is a derivative of 



URINARY ANALYSIS AND DIAGNOSIS. 

haemoglobin and is probably derived from the disintegration of haemo- 
globin. 

Urobilin is not usually present in freshly voided urine, but a small 
quantity soon forms on standing from oxidation of urobilinogen, a chro- 
mogen, which is present in fresh urine. It is formed by the reducing j 
action of putrefactive intestinal bacteria on the bile pigments, and is 
greatly increased in diseases accompanied by marked destruction of red 
blood corpuscles or extravasation of blood into the tissues, such as per- 
nicious anaemia, purpura, scurvy, cerebral apoplexy, and hemorrhagic 
infarcts. It is also increased in many febrile diseases, septic conditions, 
acute articular rheumatism, pneumonia, malaria, scarlet fever, diseases 
of the liver and bile ducts, as well as in lead colic, and has been found 
after administration of antipyrin and antifebrin. 

Detection of urobilin: Fill a test tube three-quarters with urine and 
add one drop of hydrochloric acid and 5 c.c. of amyl alcohol. Shake 
gently a few times, allow to stand a few minutes, pipette off layer of 
alcohol into another test tube, dilute with two volumes ninety-five per 
cent ethyl alcohol, add one drop of ammonia water to neutralize the acid 
added at first, and 1 c.c. five per cent alcoholic solution of zinc chloride. 
Filter off any precipitate of zinc hydroxide and observe a green fluores- 
cence of the filtrate in the presence of urobilin, destroyed by the slightest 
trace of acid. 

Of other organic constituents of normal urine, oxalic acid may be] 
mentioned. It is present in very small quantities, but is increased 
whenever there is an interference with oxidation in the body, being found 
in diseases of the heart, lungs, and liver, as well as in diabetes. It usually 
occurs in the form of calcium oxalate, a salt which crystallizes and is de 
posited in the urinary sediment when it is present in excess. The signifi 
cance of oxaluria is discussed in the chapter on crystalline and amorphous 
sediments. 

B. INORGANIC. 

The chief inorganic constituents of urine are the chlorides, phosphates, 
and sulphates which occur in combination with potassium, sodium, am- 
monium, calcium, and magnesium. In addition to these there are small 
amounts of carbonates and minute quantities of iron, fluorin, silicic acid, 
and free gases, including nitrogen, carbonic acid, and traces of oxygen. 
rhe total amount of inorganic substances excreted in twenty-four hours 
is between 12 and 27 gm. 

Chlorides.- Next to urea, the chlorides are the chief solid constitu- 
ents of the urine. The most important and most abundant of the chlo- 



NORMAL CONSTITUENTS. 29 

rides is chloride of sodium, but small quantities of chloride of potassium 
and ammonium are also present. The amount of the chlorides voided 
varies considerably with the diet, being derived from the food, and they 
are most abundant when a large amount of salty food is ingested. The 
average quantity voided is between 10 and 16 gm. (2^ to 4 drachms) in 
twenty-four hours; a milk diet considerably reduces this amount, while 
an abundance of salty food may increase it to 30 or 40 gm. In starva- 
tion the chlorides almost entirely disappear from the urine. When 
starvation is followed by feeding, they do not appear again until the 
system has reabsorbed the amount voided when starvation began. 

The excretion of chlorides is diminished in all febrile conditions, 
especially in those in which a serous exudate is formed. In pneumonia 
their excretion is greatly reduced during the florid stages of the disease, 
but rapidly increases when the exudate becomes absorbed and convales- 
cence sets in. The chlorides are also diminished in diarrhoea and may 
sink to a minimum in severe gastric disorders, such as ulcer and cancer, 
in which very little food is taken. In chronic diseases accompanied by 
oedema, such as chronic nephritis, the chlorides are considerably dimin- 
ished, and if the fluid is absorbed they gradually rise. In nephritis the 
chloride excretion usually follows the same course as the urea excretion. 
The chlorides are increased during active exercise and, as a rule, in dia- 
betes, both mellitus and insipidus. 

The chlorides may be detected by treating the urine with nitric acid 
and adding a solution of nitrate of silver ; a cheesy precipitate, soluble in 
ammonia, shows the presence of chlorides. A test of the approximate 
amount of chlorides present may be made with this method, as follows: 
To a small amount of urine in a test tube add a few drops of nitric acid, 
and to this one or two drops of a nitrate-of-silver solution, one part to 
eight. If a white, flaky precipitate is formed, which quickly sinks to the 
bottom of the test tube without diffusing through the urine, the chlorides 
are present in normal amount (from one-half to one per cent) . If a sim- 
ple cloudiness appears, readily diffusing through the urine without the 
appearance of flakes, the chlorides are diminished to one-tenth per cent ; 
and if no precipitate whatever is formed, they are entirely absent. If 
more than a trace of albumin is present it should be removed by heat 
before applying this test, as albuminate of silver forms and interferes 
with the reaction. 

For quantitative estimation Mohr's titration method with silver ni- 
trate can be used. The solutions required are: 

1. Standard nitrate-of-silver solution: Dissolve 29.075 gm. of fused 
nitrate of silver in 1.000 c.c. of distilled water; 1 c.c. of this solution is 
equal to 0.01 of sodium chloride. 



30 I IHXARY ANALYSIS AND DIAGNOSIS. 

2. A saturated watery solution of neutral potassium chromate, made 
by dissolving one part of the salt in five parts of water. 

Take 10 c.c. of urine; dilute with 50 c.c. of distilled water; add 8 to 
10 drops of potassium-chromate solution; to this mixture add the stand- 
ard silver solution drop by drop from a burette. The chlorine com- 
bines with the silver to form a silver chloride in the form of a white pre- 
cipitate. When all the chlorine is precipitated, silver chromate, red in 
color, forms, and the silver-nitrate solution must be added until a pink 
tinge appears. The number of cubic centimetres of silver solution used, 
multiplied by 0.01, will give the amount of chlorides in 10 c.c. of urine, 
from which the total for twenty-four hours is calculated. 

Phosphates.— Phosphates are found in the urine as salts of sodium, 
potassium, calcium, and magnesium. The combinations of phosphoric 
acid with sodium and potassium constitute the alkali-phosphates; the 
combinations with calcium and magnesium the earthy phosphates. The 
phosphoric-acid excretion is usually expressed in terms of P a O B ; that is, 
phosphoric-acid anhydride ; and the amount voided in twenty-four hours 
varies from 2.3 to 5 gm., the average being 3.5 gm. (less than one drachm). 
Of this amount about two-thirds is in combination with sodium and po- 
tassium (sixty per cent of' which is acid sodium phosphate), and one- third 
in combination with calcium and magnesium. A minute amount is pres- 
ent as glycero-phosphoric acid. 

The alkali-phosphates are soluble in water and acids, while the earthy 
phosphates are insoluble in water and are held in solution in acid urine, 
but are precipitated in alkaline urine, forming a sediment more marked 
if heat be applied. On heating a slightly acid, neutral, or alkaline urine, 
a precipitate forms, which may be mistaken for albumin; from this it 
may be easily distinguished by the addition of two or three drops of an 
acid, such as acetic or nitric, which quickly dissolves the earthy phos- 
phates. If the magnesium phosphate be acted upon by ammonia, the 
ammonio-magnesium phosphate — so-called triple phosphate — is formed. 

The phosphates in the urine are derived partly from the food, partly 
from the decomposition of organic substances containing phosphorus, 
such as nuclein and lecithin; they are more abundant after a vegetable 
lift and after drinking phosphatic waters. A continued increase in the 
total amount of phosphates in the urine is spoken of as phosphaturia. 
A diagnosis of this condition is usually based upon the presence in the 
urine of a dense deposit of phosphates; analyses of many of these cases, 
however, do not show an increased amount of phosphoric acid, but 
merely a diminished acidity of the urine, and the diagnosis of phosphat- 
uria should not be applied to them. 

The amount of phosphates excreted in the urine is increased in dia- 



NORMAL CONSTITUENTS. 31 

Ibetes mellitus, in diseases of the bone, such as osteomalacia and rachitis, 
iand diseases of the nerve centres. It is diminished in severe diseases of 

the kidney and in a variety of acute infections. 

The earthy phosphates may be detected by rendering the urine 

strongly alkaline with ammonia or caustic potash and gently heating, 
■which causes their precipitation in the form of a whitish cloud of feathery 
; flakes that settles to the bottom of the test tube. The precipitate is 
j dissolved on the addition of acetic acid. To detect the alkali-phos- 
Iphates, remove the earthy phosphates by precipitation and filter. To a 
I^iven quantity of the nitrate add one-third the quantity of magnesian 
f fluid (1 part each of magnesium sulphate and ammonium chloride, 8 
(parts of distilled water, and 1 part of liquor ammonia?). The alkali- 
t phosphates are precipitated in the form of a snow-white deposit. If the 
I entire fluid presents a milk-like, cloudy appearance, the alkali-phosphates 
[are present in normal amount; if it is denser and more cream-like, there 
[is an increase; but if the fluid is only slightly cloudy or remains trans- 
j parent, the phosphates are diminished. 

To estimate the amount of total phosphoric acid in the urine, the fol- 
lowing method is the best: The solutions required are: 

1. A standard solution of uranium nitrate, consisting of 35.5 gm. of 
ithe salt to 1,000 c.c. of distilled water; 1 c.c. corresponds to 5 mgm. of 

phosphoric anhydride. 

2. Sodium-acetate solution, 100 gm. of sodium acetate being dissolved 
[in 900 c.c. of water, and to this mixture 100 c.c. of a thirty per cent solu- 
tion of acetic acid being added. 

3. A saturated solution of potassium ferrocyanide, to be used as an 
indicator. 

To 50 c.c. of the urine in a glass beaker add 5 c.c. of the sodium- 
acetate solution. Heat over a water bath and add the uranium solution 
'drop by drop, as long as a precipitate forms or until a drop of the mixt- 
ure, placed upon a porcelain plate, gives a distinct brown color with a 
[drop of potassium ferrocyanide. The number of cubic centimetres of 
the uranium solution is then read off and multiplied by 0.005 (5 mgm.), 
which gives the amount of phosphoric acid in 50 c.c. of urine; from tin's 
the quantity in twenty-four hours is calculated. The end reaction, 
shown by the brown color on the porcelain dish, takes place when the 
uranium solution has precipitated all the phosphoric acid and is present 
in excess. 

Sulphates. — The sulphates occurring in the urine are of two kinds: 
first, the sulphates of sodium and potassium, the former predominating, 
known as preformed sulphates; second, the ethereal sulphates, also 
known as aromatic or conjugate sulphates. The first form ninety per 



32 URINARY ANALYSIS AND DIAGNOSIS. 

cent, the second ten per cent, of the sulphates. The quantity excreted 
by the kidneys varies from 1.5 to 3 gm. (23 to 45 grains) in twenty-four 
hours. Sulphates are extremely soluble and are never met with in the 
form of deposits, excepting calcium sulphate. They are derived partly 
from the food and partly from the decomposition of proteids in the tis- 
sues. The total quantity bears a fairly constant relation to total nitro- 
gen, being one to five. 

An increased excretion of sulphates takes place after a meat diet and 
as a result of active exercise; this is also the case in acute fevers with an 
increased excretion of urea. After taking sulphuric acid or suphates 
and after the inhalation of oxygen, they are likewise increased. Sul- 
phates are diminished after a strictly vegetable diet. 

Sulphates may be detected by adding to a given quantity of urine in 
a test tube one-third as much of an acidulated solution of barium chloride 
(4 parts of barium chloride, 16 parts of distilled water, 1 part of concen- 
trated hydrochloric acid). An opaque, milky cloudiness will appear 
when the amount of the sulphates is normal. If the opacity is intense 
and the mixture has the appearance of cream, the sulphates are increased; 
but if there is only a slight cloudiness, they are diminished. 

To estimate the amount of total sulphates the volumetric method 
may be employed. The following solutions are required: 

1. A standard solution of barium chloride, made by dissolving 30.54 
gm. of crystallized barium chloride in 1,000 c.c. of distilled water; 1 c.c. 
of this solution corresponds to 0.01 gm. of sulphuric-acid anhydride 
(SO,). 

2. A solution of potassium sulphate, containing 21.778 gm. of the 
salt in 1 ,000 c.c. of water. 

3. Pure hydrochloric acid. 

One hundred cubic centimetres of urine are rendered acid by the addi- 
tion of 5 to 10 c.c. of hydrochloric acid and heated to boiling in a flask. 
The barium-chloride solution is allowed to drop into the mixture as long 
as any precipitate occurs, the mixture being heated before each addition 
of the barium solution. After adding 5 to 8 c.c. of the solution, allow 
the precipitate to settle; filter a small portion of the mixture and add a 
few drops of the standard solution. If any precipitate occurs, return the 
whole to the flask, add more barium solution, and test as before, until no 
more precipitate is formed on the addition of barium chloride. An ex- 
cess of the latter should be avoided. 

If only a trace of excess is present, a drop of the clear fluid removed 
from the flask gives a cloudiness with a drop of potassium-sulphate solu- 
tion placed on a glass plate over a black background. If more than a 
cloudiness appears, too much barium chloride has been added, and the 



NORMAL CONSTITUENTS. 33 

test must be repeated. From the amount of barium chloride used, the 
percentage of sulphuric acid in the urine is calculated, 1 c.c. of barium- 
chloride solution corresponding to 0.01 gm. of S0 3 . 

Carbonates. — In urine of an alkaline reaction minute quantities of 
carbonate and bicarbonate of ammonium, calcium, sodium, and mag- 
nesium are present. As a result of alkaline decomposition of the urine, 
ammonium carbonate may be found in large quantities. The carbonates 
are derived from the food, especially from vegetable acids, and may be 
considerably increased after drinking alkaline mineral waters. An ex- 
cess of carbonates renders the urine turbid when passed, or it becomes so 
upon standing, and upon sedimentation the precipitate is that of calcium 
carbonate, usually associated with phosphates. 

The presence of carbonates in the urine is detected by the evolution 
of gas, upon the addition of a few drops of an acid, such as acetic or nitric. 

Other inorganic constituents, such as iron, silicic acid, fluorin, and 
hydrogen dioxide, occur in normal urine in traces only, and are of no 
clinical importance. 

Centrifugal Analysis. 

Centrifugal Analysis. — A number of years ago Purdy introduced his 
method of centrifugal analysis for the ready approximate determination 
of bulk percentages of chlorides, phosphates and sulphates, and albumin. 
This method, for which a simple, single-speed centrifuge with a gradu- 
ated sedimentation tube is sufficient, may be used for a rapid determina- 
tion of bulk percentages and for an estimation of the presence of normal, 
increased, or diminished amounts of chlorides, phosphates, and sulphates. 
The handle of the instrument is rotated at a uniform speed of sixty turns 
per minute for three minutes. 

Estimation of chlorides: Fill graduated tube to the 10-c.c. mark with 
fresh urine; add 15 to 20 drops of strong nitric acid to prevent precipita- 
tion of phosphates, and fill tube to the 15-c.c. mark with silver-nitrate 
solution (1 part to 8 of water). The ungraduated tube may be filled 
with water or urine. Mix the contents thoroughly and centrifugalize 
for three minutes, after which the quantity of bulk percentage is read off 
on the scale of the tube. The normal bulk percentage of silver chloride 
ranges from ten to twelve per cent. Each one-tenth of a cubic centi- 
metre of the precipitate calculated as chlorine is equivalent to 0.123 per 
cent by weight. 

Estimation of phosphates: Fill graduated tube to the 10-c.c. mark 
with urine; add 2 c.c. 50 per cent acetic acid and 3 c.c. uranium- 
3 



34 URINARY ANALYSIS AND DIAGNOSIS. 

nitrate solution (5 per cent). Mix contents thoroughly and centrifugal 
ize for three minutes. The normal bulk percentage of uranyl phosphate 
is eight to ten per cent. Each one-tenth of a cubic centimetre of pra 
cipitate calculated as phosphoric acid is equivalent to 0.0225 per cent bj 
weight. 

Estimation of sulphates: Fill graduated tube to the 10-c.c. mark witl 
urine; add 5 c.c. barium- chloride solution (see page 32). Mix thoroughlj 
and centrifugali ze for three minutes. The normal bulk percentage oi 
barium sulphate is about 0.8 per cent. 



•lioi 
net 



CHAPTER V. 

ALBUMINOUS SUBSTANCES. 



The term albuminous substances or proteids includes a group of 
substances related to each other though differing in constitution and 
properties. The following proteids may be found in the urine: serum- 
albumin, serum-globulin, nucleo- albumin, albumoses and peptone, haemo- 
globin, fibrin, and rarely histon and nucleo-histon, which latter are de- 
rivatives of the cell nuclei. 

The chief clinical interest centres in serum- albumin, which is fre- 
quently combined with serum-globulin, and by the term albuminuria the 
presence of these bodies in the urine, without regard to the possibility of 
the presence of other proteids, is usually meant. 

Albuminuria. — The presence of albumin in any appreciable amount 
must always be regarded as a pathological phenomenon, although minute 
quantities, which escape detection by the ordinary clinical tests, are 
present in some normal urines. The detection of albumin in the urine 
does not necessarily signify the presence of a renal trouble, but it may be 
due to a variety of causes. Even a comparatively large amount may 
exist without any kidney lesion whatever, and it is a grave mistake to 
conclude that a nephritis must exist because albumin has been found. 
Although in the larger number of cases in which albumin is found a 
nephritis is present, a microscopical examination must invariably be 
made to determine, if possible, the exact source of the albumin; and 
only if pus corpuscles and kidney epithelia, with or without the presence 
of casts, are found, a diagnosis of a nephritis is justified. 

On the other hand, a nephritis may exist and yet albumin be found 
in such minute quantities as occasionally to escape detection altogether. 
This is sometimes the case in cirrhosis of the kidney, where a large amount 
of albumin is rarely seen, and it may be entirely absent for a few hours. 
In such cases the urine of the entire twenty-four hours should be tested 
before concluding as to the presence of albumin. 

In all cases Avhere pus corpuscles in moderate numbers are found in 
the urine, albumin may always be detected, if careful tests are made, 
though there may be no more than a faint trace. It can thus easily be 
seen that in such widely different lesions as pyelitis, cystitis, prostatitis, 
urethritis, and vaginitis, it might be present in the urine, and a micro- 

35 



36 URINARY ANALYSIS AND DIAGNOSIS. 






scopical examination will be necessary to determine its origin. In hem- 
orrhage from any portion of the genito-urinary tract, a considerable 
amount of albumin is usually found. The rare cases of chyluria, in 
which the kidney may be perfectly intact, are always associated with 
the presence of a large amount of albumin. These cases of extrarenal 
albuminuria are known as pseudo- or accidental albuminuria, to differ-* 
entiate them from renal or true albuminuria. 

Disturbances of circulation, due to a variety of causes, may bring 
about the presence of albumin without any structural changes in 
the kidney or any pus corpuscles in the urine. Such cases are often 
roughly termed functional albuminurias. It is not always easy to trace 
the cause of such albuminurias, though they may be due to nothing but I 
prolonged muscular exercise, to lesions of the nervous system, or to or- L 
ganic heart lesions, etc. If long continued, these cases will sooner or L 
later cause inflammations of the kidney. Albuminuria of pregnancy, 
due to the pressure of the pregnant uterus, is very common, and in many Jj 
of these cases an organic lesion of the kidney will develop. j 

Some authors speak of a true physiological or functional albuminuria 
occurring only in the young, especially during the period of adolescence.; 
In these cases albumin is present at certain times of the day, absent at 
other times, notably after periods of rest; that is, the albuminuria is" 
cyclic. 

Changes in the composition of the blood with a broken-down constitu- 
tion, as seen in anaemia, tuberculosis, malaria, leukaemia, pyaemia, etc., 
when no lesions of the kidney can be discovered, will cause the appearance 
of albumin ; and this may also be the case in any other febrile condition. 
The effect of certain poisons upon the blood, such as strychnine, pilo- 
carpine, phosphorus, arsenic, lead, potassium chlorate, iodine, alcohol, 
and toxins, may cause the appearance of albumin in the urine. 

Before resorting to chemical tests for the detection of albumin in the 
urine, it is advisable to have the urine as clear as possible, as a cloudy 
sample renders the detection of small quantities of albumin difficult. In 
many cases a simple filtration through a double layer of filter paper is 
sufficient. Where this does not suffice, the urine should be centrifugal- 
ized and then filtered, if necessary, a number of times. If the urine is 
very cloudy, filtration through a tight plug of fine asbestos filtering fibre 
may clear it up completely. Treating the urine with different agents! 
such as magnesium oxide or talcum, is not advisable, as experiments 
have shown that thereby, not only traces, but even considerable quan- 
tities of albumin may be removed. 

Detection of Albumin in Urine. — 1. Heat Test with Acetic Acid. 
— The tests for albumin are quite numerous, but one of the most reliable 



ALBUMINOUS SUBSTANCES. 37 

the following : Fill an ordinary test tube about one-fourth or one-third 
ill of urine and boil thoroughly ; then add two or three drops of a solu- 
on composed of equal parts of glacial acetic acid and water. If albu- 
rin is present the urine becomes cloudy, the cloudiness being the more 
ronounced the larger the amount of albumin. 

The unboiled urine, as brought for examination, is either transparent 
r cloudy. When the urine is boiled the results may be the following: 

(a) The urine is transparent, and upon boiling remains unchanged, 
'his indicates normal urine. 

(b) The urine is transparent, but after boiling becomes cloudy. By 
dding a few drops of acetic acid it clears up entirely. This shows the 
resence of an increased amount of phosphates. If effervescence occurs 
pon the addition of the acid, either calcium carbonate or ammonium 
arbonate (the latter being always held in solution, and never precipi- 
ated so as to be found under the microscope) is present. 

(c) The urine is transparent, but after boiling becomes cloudy, and 
le cloudiness remains or becomes more pronounced upon the addition 
f the acid. This indicates the presence of albumin, which, in larger 
uantities, will be thrown down in flakes; when very abundant, the 
rine may be converted into a jelly-like mass. The acetic-acid test will 
how the presence of the smallest traces of albumin, though these may 
scape detection if not carefully observed. The best plan in such cases 

to take a second test tube and pour into it unboiled urine; then com- 
pare the two test tubes by holding them against a dark background. 
Vhen this is done, the faintest trace of albumin can be detected by the 
light cloudiness in the test tube containing the boiled urine. 

(d) The urine is cloudy, but upon boiling clears up entirely and re- 
nains clear upon the addition of the acid. This indicates an excess of 
\irates, especially sodium urate. 

(e) The urine is cloudy, the cloudiness disappears upon warming, but 
j'eappears and becomes more pronounced upon boiling and the addition 
j)f the acid. This shows an excess of urates, in addition to the presence of 
nlbumin. 

(/) The urine is cloudy, and remains unchanged by boiling and by 
! ;he addition of acetic acid. This proves the presence of micro-organisms, 
huch as micrococci and bacilli. 

As nucleo-albumin and mucin are also precipitated by this test, 
Purdy recommends the following method for performing it: Have on 
hand a saturated aqueous solution of sodium chloride. Fill a clean test 
tube about two-thirds full of the previously filtered urine, and add to 
this about one-sixth of its volume of the sodium-chloride solution. Next 
add five to ten drops of acetic acid (fifty per cent) and gently heat the 



38 URINARY ANALYSIS AND DIAGNOSIS. 

upper inch or so of the contents of the test tube for about half a minute. 
If albumin be present, even in the minutest traces, it will appear in the 
upper, boiled portion of the test tube if examined in good light. For all 
practical purposes, however, the original test, as given above, is perfectly 
sufficient and is undoubtedly more accurate and sensitive than the nitric- 
acid test. 

2. Heat Test with Nitric Acid. — A common test for albumin is the 
nitric-acid test, the urine being boiled and a few drops of nitric acid 
added. This test is not as reliable as the preceding, since, if a small 
amount only of albumin be present and the acid added be in excess, the 
albumin may become redissolved. On the other hand, if the amount of 
acid added is small and the phosphates are present in excess, a part only 
of the basic phosphates will be acidified and a soluble albuminate will be 
formed, which remains in solution. 

3. Heller's Test. — Another frequently employed test, known sim- 
ply as ''the nitric-acid test/' is used as follows: Place a small quantity 
of pure nitric acid in a test tube and allow an equal amount of clear, 
previously filtered urine to trickle from a pipette down the side of the 
inclined tube, so that the urine overlies the acid. If albumin is present, 
a distinct, sharp, white zone will appear at the point of contact between 
the acid and the urine, varying in thickness according to the amount of 
albumin present and according to the rapidity with which the urine is 
dropped into the tube. If only a trace of albumin be present, a number 
of minutes may elapse before the zone becomes visible. 

This test can also be performed by first pouring the urine into the 
test tube and then allowing the nitric acid to flow down the sides of the 
tube; the acid, being heavier than the urine, will form a separate layer 
below the urine. 

Other substances in the urine may give rise to the formation of a 
nitric-acid ring, and if care is not taken will be mistaken for the zone 
caused by the presence of albumin. Thus in concentrated urines urates 
may form a zone, which, however, does not appear at the point of con- 
tact between the acid and the urine, but above the point of contact, and 
spreads downward; it will disappear on heating. Uric acid and urea, if 
present in large amounts, may be precipitated, but are recognized by 
their crystalline nature. Mucin is also precipitated, but is dissolved by 
the excess of nitric acid at the point of contact. Nucleo-albumin and 
albumoses are likewise precipitated; the former gives a fainter ring than 
albumin, which is above the point of contact, while the ring formed by 
the latter disappears on heating and reappears on cooling. 

4. Potassium-ferrocyanide Test.— To 10 c.c. of previously fil- 
tered urine add five drops of strong acetic acid. If a precipitate appears, 



ALBUMINOUS SUBSTANCES. 39 

it is due to nucleo-albumin or mucin and should be filtered off. Then 
add a few drops of a five to ten per cent potassium-ferrocyanide solu- 
tion. If a small amount of albumin be present, a faint cloudiness at 
once appears; if a larger amount be present, a flocculent precipitate 
forms at once. Albumose also gives a cloudiness, which, however, disap- 
pears upon heating. 

5. Spiegler's Test. — This test, as modified by Jolles, consists in 
adding to 4 or 5 c.c. of previously filtered urine 1 c.c. of a thirty per cent 
acetic-acid solution and 4 c.c. of the reagent. The latter is composed of 
10 gin. mercuric chloride, 20 gm. succinic acid, and 20 gm. sodium chlo- 
ride, in 500 c.c. of water. In adding the solutions care must be taken 
that they are not mixed with each other, but layered over each other. 
If albumin be present, a distinct, sharp, white zone, which is especially 
plain on holding the test tube against a dark background, at once ap- 
pears. 

6. Sulpho-salicylic-acid Test. — Acid two or three drops of a 
twenty per cent watery solution of sulpho-salicylic acid or a few small 
crystals of the acid to 4 or 5 c.c. of urine in a test tube, and mix thor- 
oughly. If small amounts of albumin are present, an opalescent cloudi- 
ness appears; if larger amounts are present, a pronounced turbidity or 
heavy precipitate forms. Albumose is also precipitated by this test, but 
disappears on heating, to reappear on cooling. 

7. Biuret Reaction. — The urine is first treated with a ten per cent 
solution of sodium or potassium hydrate, and then a ten per cent solution 
of cupric sulphate is, added drop by drop. If serum- albumin and globu- 
lin alone are present, the liquid turns pure violet; if albumoses and pep- 
tone alone are present, it turns rose; if several of the albumins are pres- 
ent together, the urine assumes tints intermediate between violet and 
rose. Care should be taken not to add too much cupric sulphate, since 
if the urine contains only small amounts of albumin, the color of the 
copper solution will cover the color of the biuret reaction. 

8. Picric-acid Test. — To a given amount of previously filtered 
urine in a test tube add an equal amount of a saturated solution of picric 
acid. If albumin is present, a precipitate forms, varying from a light 
cloud to heavy flakes, according to the amount of albumin. This test is 
delicate, but precipitates other substances besides serum- albumin, which, 
however, will disappear on heating. 

For performing a number of the above-described tests, but more 
especially Heller's test, a small glass instrument, known as the horis- 
mascope (see Fig. 11), can conveniently be used. The urine to be tested 
is poured into the large tube, and the reagent into the small tube. The 
reagent, being of higher specific gravity than the urine, flows down the 



40 



URINARY ANALYSIS AND DIAGNOSIS. 



capillary tube and forms a layer under 'the urine. The slightest opacity 
at the contact point of the two fluids is easily seen against a black back- 
ground. 

Numerous tests besides these here given have been described and 
have found their adherents. Few authors will agree as to the most reli- 
able test for albumin, some preferring the more delicate tests, such as 
Spiegler's and the sulpho-salicy lie-acid tests, others Heller's and the 
ferrocyanide tests, still others the heat tests. For all practical purposes, 
the first test given— the heat and acetic-acid test— is perhaps the most 
reliable. If doubt remains as to the presence of albumin, any of the 
other tests described will clear up the question. 

Quantitative Tests for Albumin.— It is of the utmost importance to 
have an approximate idea of the quantity of albumin present in any 




Fig. 11. — Horismascope. 



Fig. 12. — Esbach's Albuminometer. 



given case, and too many errors are constantly made in this respect. It 
is by no means rare to hear of a urine containing twenty-five, forty, or 
even fifty per cent of albumin. What is thereby meant is, of course, per 
volume; yet such statements are absolutely misleading. As a matter of 
fact, one-tenth of one per cent is a moderate amount of albumin, one- 
twenty-fifth of one per cent being a small amount; one-half of one per 
cent is a large amount, and it is only in comparatively rare cases that 
one per cent or more is present ; more than four or five per cent is prob- 
ably never found. 

The simplest method of estimating the approximate amount of albu- 
min is by means of Esbach's albuminometer (see Fig. 12). This instru- 



ALBUMINOUS SUBSTANCES. 41 

ment consists of a graduated glass tube, which is filled with urine to the 
letter U marked upon the tube, and with the test solution to the letter 
R. The latter consists of one part of picric acid to coagulate the albu- 
min, two parts of citric acid to hold the phosphates in solution, and dis- 
tilled water to make one hundred parts. The tube is now closed with 
the rubber stopper supplied with it, and the contents thoroughly mixed. 
It is then set aside for twenty-four hours to allow the precipitate to settle 
thoroughly, and the amount of the precipitate carefully noted. The 
tube contains a number of main lines of division, each one of which sig- 
nifies 1 gm. of albumin in 1,000 gm. — that is, one-tenth of one per cent. 
Many of the instruments are only graduated for seven-tenths of one per 
cent, and this is sufficient for most cases. In those rare cases in which 
more than that amount of albumin is present, the urine must be diluted 
with one, two, or even three parts of water before testing. It must al- 
ways be borne in mind that this method can never be absolutely accu- 
rate, since picric acid will also precipitate urates, peptone, and vegetable 
alkaloids; but it undoubtedly gives an approximate idea, which is all 
that is required in most cases. 

Creatinin may be an important factor which causes errors in Esbach's 
instrument. An entire precipitate has been found to be a compound of 
potassium picrate with creatinin; it was detected by macroscopical ap- 
pearance and proved by recrystallization from hot water. Albumin can- 
not be recrystallized, and we must guard against this possibility of results 
much too large by Esbach's method. 

The centrifugal method is still more inexact, but being performed in 
a few minutes, may be employed for a rough estimation of the amount 
of albumin. Fill the graduated tube to the 10-c.c. mark with urine; add 
3^ c.c. of a ten per cent potassium-ferrocyanide solution; agitate slightly 
and add 1^ c.c. of a fifty per cent acetic-acid solution, after which the 
contents of the tube should be thoroughly mixed. Centrifugalize for 
three minutes or until the fluid is perfectly clear. Each division of the 
tube represents one per cent of albumin by measure, but not by weight. 
It has been found that in order to find the percentage of albumin by 
weight from this bulk measure, the latter, expressed in tenths of a cubic 
centimetre, must be divided by 6. Urines containing a very large amount 
of albumin should be diluted with one, two, or three volumes of water 
and the readings multiplied by 2, 3, or 4, as the case may be. 

An approximate estimation of the amount of albumin can be obtained 
from the amount of precipitate in the bottom of the test tube after using 
the heat and acetic-acid test. A mere clouding is a faint trace, trace, or 
more than trace, according to the degree of the clouding; a small but 
perceptible precipitate is one-fortieth to one-thirtieth per cent; if the 



42 URINARY ANALYSIS AND DIAGNOSIS. 

precipitate forms about one-twentieth of the column of urine, the amount 
of albumin is one-twentieth per cent ; if it forms about one-tenth of the 
urine column, one-tenth per cent; one-quarter of the urine column, one- 
fifth to one-fourth per cent ; and one-half of the urine column, two-fifths 
to one-half per cent of albumin. 

The most exact method for the determination of the amount of albu- 
min is the gravimetric method, which consists in coagulating the albumin 
either by heating or by means of chemical agents, filtering out the albu- 
min, collecting, drying, and weighing. It is too elaborate for clinical 
work. 

Besides serum albumin, the urine may contain a number of. similar 
but less important substances, among which may be mentioned globulin, 
albumose, peptone, mucin, and fibrin. 

Globulin. — Globulin is almost always associated with serum-albumin 
in every albuminous urine, and its clinical significance is nearly identical 
with the latter. It is, however, more abundant than serum- albumin in 
many cases of acute nephritis and in chronic nephritis with waxy degen- 
eration of the kidney, also in some cases of pneumonia. 

Globulin can be detected by the method of Pohl in the following 
manner: Render the urine neutral or even slightly alkaline by the addi- 
tion of ammonium hydrate, and filter after standing one or two hours; 
then add an equal volume of a saturated solution of ammonium sulphate. 
If globulin is present, a white, flocculent precipitate forms immediately. 

Another simple method depends upon its insolubility in diluted urine. 
Dilute a certain amount of previously filtered urine with ten times the 
amount of distilled water, and a flocculent precipitate appears; this is 
hastened by the addition of one or two drops of dilute acetic or boric acid. 
Or, fill a test tube with water, and allow a few drops of the albuminous 
urine to fall into it. If globulin is present in any quantity, each drop of 
urine as it falls is followed by a milky streak, and after a number of drops 
have been added the water assumes a milky opalescence throughout. 

Albumoses. — The term albumoses or proteoses includes a number of 
albuminous bodies which are intermediate products between albumin and 
peptone, the end-product of digested albumin. They are formed in the 
body by the action of the gastric and pancreatic juices. The}' are not 
coagulated by heat, but are precipitated by acids, the precipitate thus 
formed being redissolved by heat. The albumoses are divided into 
primary and secondary; the primary are proto-albumose and hemi- or 
hotero-albumose; the secondary are deutero-albumoses, which so closely 
resemble peptone in its reactions that they cannot always be differen- 
tiated from the latter. 



ALBUMINOUS SUBSTANCES. 43 

The clinical significance of the albumoses is not yet positively known. 
They have been found in urine in a number of different conditions, such 
as ulceration of the intestines, tertiary syphilis, hemiplegia, cancer, 
double pneumonia, scarlet fever, diphtheria, muscular atrophy, and 
abscesses. 

Albumoses are detected by their solubilities and reactions. Proto- 
and deutero-albumose are soluble in hot and cold water, while hetero- 
albumose is insoluble in water; all three are soluble in ten per cent 
solutions of sodium chloride. The primary albumoses are precipitated 
by strong solutions of sodium chloride and magnesium sulphate; also by 
saturated solutions of ammonium sulphate and by cold nitric acid. Sec- 
ondary albumose is not precipitated by strong solutions of sodium chlo- 
ride and magnesium sulphate, but is precipitated by ammonium sul- 
phate; with nitric acicl it is only precipitated in the presence of an excess 
of sodium chloride. 

Another albumose, known as Bence- Jones albumose, differs from 
those just described in being coagulated by heat. It is not identical 
with the other albumoses, and its occurrence in urine is rare. It has 
been found in cases of osteomalacia and multiple sarcomata. 

Peptones. — Peptones are the final products of gastric and pancreatic 
digestion. They cannot always be differentiated from albumoses, since 
both have many reactions in common; and the term peptonuria, fre- 
quently employed, is not strictly correct, as albumoses and peptones are 
usually found together. 

Peptones are frequently found in man)' different pathological condi- 
tions. Among these may be mentioned croupous pneumonia, pulmonary 
tuberculosis, gangrene of the lungs, empyema, cancer (especially of the 
gastro-intestinal tract and the liver), phosphorus-poisoning, septicaemia, 
acute yellow atrophy of the liver, typhoid fever, typhus fever, variola, 
scarlet fever, erysipelas, acute arthritis, and suppurative conditions gen- 
erally. Some authors claim that peptone is invariably present when 
pus has formed somewhere in the body, and consider it of diagnostic 
significance in cases in which the clinical features are not sufficiently 
clear for a positive diagnosis. Thus it is considered possible to decide 
as to the presence of a purulent or a tubercular meningitis, a purulent 
or serous arthritis, an empyema or serous pleurisy, etc. Peptones 
have, however, also been found in physiological conditions, such as 
the involution of the pregnant uterus — so-called puerperal pep- 
tonuria — so that their presence does not necessarily signify a diseased 
condition. 

Peptones are easily soluble in water, do not coagulate by heat, and 
do not precipitate by the addition of most of the reagents used for the 



44 UEINAEY ANALYSIS AND DIAGNOSIS. 

detection of albumin, such as acetic acid, nitric acid, and potassium 
ferrocyanide. They are precipitated by tannin, potassio-mercuric io- 
dide, picric acid, and phosphotungstic acid. 

They may be detected by the following method : To urine which has 
been slightly acidified by acetic acid, add a saturated solution of mag- 
nesium or ammonium sulphate, and filter out any precipitate formed, 
which may consist of albumin, globulin, or the albumoses. If potassio- 
mercuric iodide or picric acid is now added and a precipitate occurs, it 
consists of peptone. 

Another test is the following: 10 c.c. of urine are acidified with one 
or two drops of hydrochloric acid, the mixture precipitated with a five 
or ten per cent solution of phosphotungstic acid, and heated. The 
supernatent fluid is poured off and the precipitate dissolved in a few 
cubic centimetres of distilled water to which a small amount of caustic 
soda is added. The solution is heated until it turns yellow. After cool- 
ing, the addition of a few drops of dilute copper-sulphate solution should 
give a reddish color. 

Mucin (Nucleo- albumin) . — Mucin is present in small amount in 
every normal urine, being more abundant in the urine of females, chiefly 
from the vaginal secretion. It is derived from the epithelia of the genito- 
urinary organs, and is considerably increased in inflammations of these 
organs, more especially those of the bladder, the urethra, prostate gland, 
and vagina. When present in large amount, the urine appears cloudy 
soon after it is voided, and it may form a ropy, jelly-like mass, which 
sinks to the bottom of the vessel. 

To detect its presence in urine, dilute with two or three times the 
amount of water to prevent a precipitation of uric acid upon addition of 
acid. After dilution add an excess of acetic acid. If mucin is present, 
a more or less pronounced precipitate forms. The precipitate may be 
purified by dissolving in water with a small amount of caustic soda, and 
reprecipitated by acetic acid. To detect it in urine containing consider- 
able albumin, precipitate the albumin by boiling, and test again with 
acetic acid. Even small amounts can be readily detected with the mi- 
croscope. 

Fibrin. — Fibrin, the coagulum from blood, lymph, and exudates, is 
found in the urine in greater or less amount in hemorrhages from the 
gcnito-urinary tract due to various causes, and is also seen in chylous 
urine. In tumors of the bladder, such as papilloma and cancer, where 
hemorrhages occur frequently, it is of common occurrence. It is usually 
present in the form of coagula when the urine is voided, or may be pre- 
cipitated upon standing. 

Fibrin is insoluble in water, alcohol, ether, and in salt solutions, as 



ALBUMINOUS SUBSTANCES. 45 

well as in weak acids and alkalies. The addition of weak acid solutions, 
such as hydrochloric acid, causes it to swell up into a gelatinous mass, 
which becomes soluble after prolonged boiling. The solutions give the 
general reactions of albumin. It is, however, much easier to detect its 
presence by the microscope. 



CHAPTER VI. 

CARBOHYDRATES. 

A. GRAPE SUGAR. 

Grape sugar, dextrose, or glucose (C 6 H ]2 6 ) is the only important 
carbohydrate found in urine. There can be little doubt that the urine 
may contain small amounts of sugar under normal conditions, but the 
amount is so minute, usually less than 0.02 per cent, that a positive re- 
action is not obtained with the general methods of detecting dextrose. 

The presence of grape sugar in the urine in appreciable amounts tem- 
porarily does not necessarily signify the existence of diabetes, any more 
than the presence of albumin signifies the existence of a nephritis. After 
a diet rich in carbohydrates or the ingestion of considerable quantities 
of sweet alcoholic beverages, sugar may appear in the urine temporarily; 
such a condition is spoken of as a physiological or alimentary glycosuria. 

Pathologically, glycosuria may appear in the urine as a temporary 
condition {transitory glycosuria) in the course of a number of diseases, 
such as Asiatic cholera, intermittent fever, affections of the heart, lungs, 
liver, brain, and spinal cord; alcoholism, gout, and tumors of the pan- 
creas. It may occur during pregnancy and in the course of acute con- 
tagious diseases, such as scarlatina. Furthermore, glycosuria may be 
present in poisoning with certain drugs, such as the alkaloids of opium, 
chloral, chloroform, amyl nitrite, caffeine, curare, and carbonic oxide; 
also after the use of large doses of thyroid extract. 

Whenever sugar is persistently present in appreciable quantity, we 
always have to deal with diabetes mellitus. This disease has been ob- 
served at all ages, and large amounts of sugar may be found ; 500 gm. in 
twenty-four hours are not rare, 200 to 300 gm. being the average ; more 
than nine or ten per cent are, however, not often excreted. In the 
milder cases no sugar may be present in the morning urine; hence it is 
important to examine the urine at different times of day. In the severer 
cases it is never absent from the urine. The amount of sugar does not 
seem to be a criterion for the severity of the case. A large amount of 
pale or straw-yellow urine, even with a comparatively low specific grav- 
ity, should always be an indication to examine for sugar, even if no other 
clinical evidences point toward the presence of the disease. 

46 



CARBOHYDRATES. 47 

Detection of Sugar in Urine. — The tests for sugar are numerous, and 
in mild cases it may be necessary to resort to two or even three different 
tests before we are positively able to determine the presence of sugar. 

1. Moore-Heller Test. — Perhaps the simplest is the Moore-Heller 
test. Although by no means absolutely reliable, it is in many cases suffi- 
cient to determine the approximate amount of sugar. The method is 
the following: Pour into a test tube two parts of urine and one part of a 
ten per cent caustic-potash solution; boil the upper portion for two or 
three minutes. Phosphates, if precipitated in large amount, must be 
filtered off. When sugar is present a change of color will take place after 
boiling, which can be approximately estimated as follows: One per cent 
or less of sugar gives a canary-yellow color, the color being somewhat 
more intense than that of the original unmixed urine; between one and 
two per cent gives a wine-yellow color; between two and three per cent, 
a sherry color ; between three and four per cent, a rum color ; and above 
four per cent, a dark brown or even black color. By the addition of a 
few drops of nitric acicl, the liquid loses its dark color and gives out an 
odor similar to molasses. 

This test is only a tolerably reliable one, but in many cases will answer 
the purpose. The addition of caustic potash to cold urine may produce 
a dark color, which is due to the presence of coloring matters of the bile. 
The white flocculent precipitate, which is almost invariably seen with 
this test, is partly due to the phosphates which caustic potash may pre- 
cipitate in cold urine, and partly to mucin. The presence of a large 
amount of mucin may give a similar reaction. 

The most commonly used methods of searching for sugar in the urine 
are the copper tests. They all depend upon the fact that in alkaline so- 
lutions grape sugar reduces copper salts to oxide. 

2. Trommer's Test. — The oldest of these tests is Trommer's, which 
is used in the following manner: To one or two parts of urine in a test 
tube add one part of caustic potash or soda, adding, drop by drop, a ten 
per cent solution of sulphate of copper, and shake until the mixture 
shows a blue color. Heat the upper part of the mixture, and if sugar is 
present a precipitate of yellow cuprous hydroxide will result, which at 
first shows plainly in the bluish liquid, but gradually spreads over the 
entire fluid, and a red sediment of cuprous oxide is formed. 

If this reaction takes place upon heating, a similar mixture may be 
made and set aside for a number of hours without heating; if sugar is 
present in rather large quantities, a similar precipitate will form. Should 
the reaction by heating be at all doubtful, the second test must always be 
made, since many of the other organic substances, which reduce the salts 
of copper, do so only after heating and boiling. 



48 UBINABY ANALYSIS AND DIAGNOSIS. 

This test is open to a number of objections. Albumin, if present in 
large quantities, must first be removed, since it interferes with the reduc- 
tion of the cupric oxide. A number of substances are, furthermore, 
found in urine which have the property of reducing copper oxide in an 
alkaline solution, among which may be mentioned uric acid, creatinin, 
hippuric acid, and mucin. Again, a small amount of sugar may be pres- 
ent in urine and fail to reduce the oxide in the presence of other sub- 
stances, such as urate of ammonium, chloride of ammonium, and other 
ammoniacal compounds. 

3. Fehling's Test. — Fehling's reagent consists of two solutions, the 
copper solution and the alkaline solution. 

(1) Copper solution: Dissolve 34.639 gm. of pure crystallized copper 
sulphate in a sufficient quantity of water under gentle heat, and dilute 
with water to 500 c.c. 

(2) Alkaline solution: Dissolve 173 gm. of chemically pure crystal- 
lized potassium and sodium tartrate and 100 c.c. of caustic-soda solution, 
of a specific gravity of 1.120, in sufficient water to make 500 c.c. 

These solutions must be kept in separate bottles in a dark place and 
equal volumes mixed before using. Ten cubic centimetres of this solu- 
tion will be reduced completely by 0.05 gm. of sugar. Even if kept sepa- 
rately Fehling's solution may decompose, and will then give a precipitate 
on heating, without the addition of urine containing sugar. 

The solution may be used by pouring a small quantity into a test tube 
and diluting it with two or three times the amount of water. The mixt- 
ure should be boiled for a few seconds. If it remains clear after boiling, 
which will usually be the case when the two solutions are kept separate 
and are not too old, add the urine to be tested drop by drop, at the same 
time continuing the boiling. If sugar be present in any quantity, the 
first few drops will usually cause a yellow precipitate ; if the addition of 
urine is continued, a yellowish-red sediment will soon fall to the bottom 
of the test tube. Should no such precipitate occur, the addition of urine 
may be continued until an equal volume of urine has been added ; if then 
no yellow precipitate appears upon boiling, the urine is free from sugar. 

4. Haines' Test. — This is a modification of Fehling's, for which 
stability is claimed, if well prepared, though kept on hand indefinitely. 
The improved formula consists of 2 gm. (30 grains) of pure copper sul- 
phate and 16 c.c. (one-half ounce) of distilled water; make a perfect 
solution and add 16 c.c. (one-half ounce) of pure glycerin; mix thor- 
oughly, then add 160 c.c. (5 ounces) of liquor pot assse. 

In testing with this solution, pour about 4 c.c. (1 drachm) into a 
test tube and boil it gently. Next add six to eight (Jrops of the urine 
and again boil. If sugar be present, a copious yellow or yellowish-red 



CAEBOHYDEATES. 49 

precipitate is formed. If no such precipitate occurs, sugar is not 
present. 

Besides the copper tests, bismuth tests are also used; these depend 
upon the power of grape sugar to reduce the salts of bismuth, giving a 
black precipitate. Of these, a simple test is the following: 

5. Bottger's Test. — Pour one part of urine into a test tube and add 
an equal quantity of a concentrated solution of carbonate of soda or 
caustic potash, and a small quantity of subnitrate of bismuth. Boil for 
a short time. If sugar is present, a gray or black precipitate appears, 
which will be deposited on the sides of the test tube. If the quantity of 
sugar is small, a grayish color appears. Albumin, if present in large 
quantities, must first be eliminated by boiling and filtration. 

6. Phenylhydrazin Test. — Phenylhydrazin forms with dextrose a 
compound known as phenylglucosazon, which is almost insoluble in cold 
water and separates in hot solutions in a characteristic crystalline form. 
This test is performed as follows: Pour 10 c.c. of the urine into a test 
tube and add to it 0.4 gm. of phenylhydrazin hydrochloride and 0.8 gm. 
of sodium acetate; immerse the test tube in a water-bath and boil for 
one-half to one hour; remove the tube and set it aside to cool. At the 
end of half an hour typical crystals of phenylglucosazon separate when 
sugar is present. These crystals appear under the microscope in the 
form of fine, bright yellow needles, arranged in bundles, sheaves, or ro- 
settes. 

These six tests represent only a fraction of those in use, but are the 
more important. The others offer no advantages over those described. 

Quantitative Tests for Sugar. — For a rough quantitative determina- 
tion of sugar in the urine, the Moore-Heller test, previously described, 
can be used. It is, however, not very accurate, and of little value if the 
amount of sugar is below one per cent. Of the other methods employed 
for quantitative estimation, the fermentation tests and Fehling's test 
are the simplest and are fairly accurate. The method by means of the 
polariscope is probably the most accurate when the amount of sugar ex- 
ceeds one per cent. It depends upon the fact that dextrose rotates 
polarized light toward the right, and that the degree of rotation varies 
in proportion to the percentage of sugar in the urine. The different in- 
struments devised for this purpose are elaborate and costly. 

Fehling's Test. — The principle upon which Fehling's solution de- 
pends lies in the fact that, in the reduction of oxide of copper by grape 
sugar, the blue color disappears by the addition of a definite quantity of 
the sugar. As before said, 10 c.c. of the solution correspond to 0.05 gm. 
of sugar. The test may be conducted in the following manner: Dilute 
1 c.c. of Fehling's solution with 4 c.c. of water in a test tube, and, after 
4 



50 



URINARY ANALYSIS AND DIAGNOSIS. 



heating, add 0.1 c.c. of the urine to be examined from a graduated pipette. 
Heat must be then reapplied, the precipitate watched, another 0.1 c.c. 
added, and the heat again applied, until, after allowing it to stand for a 
short time, it is found that all the blue color is removed from the solution. 
If, in doing this, 1 c.c. of urine has been added, it contains one-half of one 
per cent of sugar; if more than 1 c.c, it contains less than one-half per 
cent, but more than one-fourth per cent; if 2 c.c. are used, it contains 
one-fourth per cent; and if 0.5 c.c. is used, it contains one per cent of 
sugar. If the proportion of sugar is large, as is usually the case with a 
high specific gravity, the urine should be diluted five to ten times. 

Roberts' Fermentation Test. — This is an excellent and simple 
test, being used as follows: Into each of two bottles, one of four ounces, 
the other of twelve ounces capacity, pour 4 
ounces of urine. Add a piece of fresh yeast 
the size of a walnut to the urine in the larger 
bottle/which must be closed with a cork nicked 
for the escape of gas evolved by fermentation. 
The smaller bottle must be tightly corked, 
and the two bottles placed side by side in a 
uniform temperature of 68° to 75° F.— the 
average temperature of the room. At the end 
of twenty-four hours fermentation will be com- 
pleted. The specific gravity of each specimen 
must then be carefully taken by means of the 
urinometer, and the difference of the specific 
gravity indicates the number of grains of sugar 
per fluidounce. For example, if the specific gravity of the unfermented 
urine is 1.035 and that of the fermented urine 1.020, the urine con- 
tains 15 grains of sugar to the fluidounce, or 3 per cent. This test, 
although not absolutely accurate, is sufficiently so for practical purposes. 
Einhorn's Fermentation Saccharometer. — One of the simplest 
tests, which will be found to answer all purposes, is by means of Em- 
horn's fermentation saccharometer (see Fig. 13). The apparatus is put 
up in the form of a set, consisting of two saccharometers and one gradu- 
ated test tube. The method is the following: Take 1 gm. (about 15 
grains) of fresh commercial compressed yeast, and shake thoroughly in 
the graduated test tube with 10 c.c. of the urine to be examined. Then 
pour the mixture into the bulb of the saccharometer. By inclining the 
apparatus the mixture will easily flow into the cylinder, thereby forcing 
out the air. Owing to the atmospheric pressure, the fluid does not flow 
back, but remains there. Leave the apparatus undisturbed for twenty 
or twenty-four hours in a room of ordinary temperature. 




Fig. 13. — Einhorn's Fer- 
mentation Saccharom- 
eter. 



CARBOHYDRATES. 51 

If the urine contains sugar, the alcoholic fermentation begins in about 
twenty to thirty minutes. The evolved carbonic-acid gas gathers on the 
top of the cylinder, forcing the fluid back into the bulb. On the following 
day the upper part of the cylinder will be found filled with carbonic-acid 
gas. The changed level of the fluid in the cylinder shows that the sugar 
reaction has taken place, and indicates, by the numbers upon the cylin- 
der to which it corresponds, the approximate amount of sugar present. 
If the urine contains more than one per cent of sugar, it must be diluted 
with water before being tested; urine of a specific gravity of 1.018 to 
1.020 may be diluted twice; of 1.021 to 1.028, five times; 1.029 to 1.038, 
ten times. 

In carrying out this test it is always advisable to take, besides the 
urine to be tested, a normal specimen, and make the same fermentation 
test with it. The mixture of the normal urine with yeast will, on the 
Allowing day, have only a small bubble on the top of the cylinder. This 
proves at once the efficacy and purity of the yeast. If, in the suspected 
urine, there is also a small bubble on the top of the cylinder, no sugar is 
present; but if there is a much larger gas volume, we are sure that the 
urine contains sugar. 

B. OTHER CARBOHYDRATES. 

Fruit sugar, levulose (C 6 H ]2 6 ), is rarely found in urine, and may be 
associated with dextrose in diabetes. It has been found in cases of mel- 
ancholia and impotence, but its exact clinical significance is not under- 
stood. Levulose rotates polarized light to the left, in contradistinction 
to dextrose, which rotates it to the right. It reduces salts of copper, 
but more feebly than dextrose. 

Levulose gives a typical reaction, known as SeliwanofFs reaction: To 
10 c.c. of urine add a small amount of resorcin and 2 c.c. diluted hydro- 
hloric acid; mix and heat in a test tube. If levulose is present the liquid 
burns red and precipitates a dark sediment, which is soluble in alcohol 
vvith a bright red color. 

Milk sugar, lactose (C ]2 H l2 O n ), is sometimes found in the urine of 
nursing women, but is usually present in small amount only, rarely more 
than one per cent. Pavy has found it as late as five months after partu- 
rition in women in whom an overabundance of milk secretion was pres- 
?nt, as weir as in some women who interrupted the nursing of their chil- 
dren. It has no pathological significance, but is important because it 
may be mistaken for dextrose. 

Lactose may be detected with Rubner's test: To 10 c.c. of urine add 
3 gm. of lead acetate; filter off the precipitate and heat the filtrate in a 
test tube for a few minutes, until a yellowish-brown color appears ; now 



52 URINARY ANALYSIS AND DIAGNOSIS. 

add ammonia and continue heating. If lactose is present, a brick-red 
color appears in the solution and a cherry-red or copper-colored precipi- 
tate settles at the bottom of the test tube, while the supernatent fluid 
becomes colorless. 

Maltose or isomaltose (C i3 H ia O n ) has been found in a number of 
cases of disease of the pancreas in very small amount, usually not more 
than 0.1 to 0.5 per cent. For its isolation from the urine complicated 
methods are necessary, and its detection is of no great practical value. 



!■ 






CHAPTER VII. 

OTHER ABNORMAL CONSTITUENTS. 

Acetone. — Acetone (C 3 H 6 0) is found in minute amount in normal 
urine (0.01 gm. in twenty-four hours), but is considerably increased in 
many different pathological conditions. It seems to be a decomposition 
product of albumins, although carbohydrates and fat may also be con- 
tributors to its increased formation. 

The most important pathological condition in which acetone is found 
is diabetes (diabetic acetonuria) . In the milder cases of the disease it is 
not increased, but in the severer cases of diabetes the amount of acetone 
excreted is usually large, and it is frequently associated with diacetic and 
/5-oxy butyric acids. Acetone in varying amounts is also present in the 
urine in different febrile Conditions, in pneumonia, typhoid fever, scar- 
latina, variola, in some malignant tumors, in derangements of digestion, 
in mental diseases, after chloroform narcosis, in starvation, and after 
poisoning with many different toxic substances. Urine containing a 
large amount of acetone has a peculiar, sweet, wine or fruity odor. 

The simplest method of detection is with LegaVs test: Prepare a fresh, 
strong solution of sodium nitro-prusside by dissolving a few fragments in 
a little water in a test tube. To a few cubic centimetres of the urine add 
enough liquor sodse or liquor potassse to secure a distinct alkaline reac- 
tion, and to this add a few drops of the nitro-prusside solution, when a 
red colors at once appears from creatinin. This color changes slowly to 
straw-yellow, but if acetone is present the addition of a few drops of 
concentrated acetic acid produces a purple or violet-red; if no acetone is 
present, the latter change does not occur. 

Another test is Lieben's iodoform test, which is best applied to the dis- 
tillate of the urine; 200 or 300 c.c. of the urine, after the addition of a 
small amount of phosphoric or hydrochloric acid in the proportion of 3 
c.c. to 100 c.c, must be distilled and the tests performed with the first 
10 or 15 c.c. of distillate. To the distillate add a few drops of strong 
potassium-hydrate solution and a few drops of an iodine and potassium- 
iodide solution. If acetone is present, a yellow precipitate of iodoform 
develops at once, which can be easily identified by its characteristic odor 
and by the appearance of characteristic thin, yellow, hexagonal plates or 

53 



54 URINARY ANALYSIS AND DIAGNOSIS. 

star-like groups under the microscope. The same reaction is given by 
other substances which may occur in urine, notably alcohol, but more 
slowly. 

This test has been modified by Gunning to prevent confusion with 
alcohol. He adds an excess of an alcoholic iodine solution and some 
ammonia to the distillate or the urine itself, and if acetone is present 
iodoform is deposited. At first the liquid often turns black from the 
precipitation of nitrogen iodide, but as the precipitate settles and disap- 
pears, the yellow iodoform deposit can easily be recognized. The mixt- 
ure must not be warmed as long as it contains nitrogen iodide, this 
being a dangerous explosive. 

Diacetic Acid. — The presence of diacetic or aceto-acetic acid 
(C 4 H O 3 ) in the urine is usually of grave significance. It is rarely, if ever, 
found in urine free from acetone. Diacetic acid is found in advanced 
stages of diabetes, in severe fevers, malignant scarlatina, diphtheria, and 
measles, in cancer of the stomach and intestines, as well as in some ner- 
vous disturbances. 

Diacetic acid decomposes rapidly and is converted into acetone and 
carbon dioxide, hence the tests for it should be carried out with per- 
fectly fresh urine. 

The best test is Gerhardt's ferric-chloride reaction. To fresh urine 
carefully add a few drops of a moderately strong watery solution of ferric 
chloride. The first few drops produce a yellowish precipitate of ferric 
phosphate, and the addition of the reagent is continued until all the 
phosphates are removed; if diacetic acid is present, the addition of a 
few more drops of ferric chloride will produce a t} r pical Bordeaux-red 
color. If the amount of diacetic acid is small, the phosphate precipitate 
should be filtered off and ferric chloride added to the filtrate. The red 
color disappears on boiling for two minutes ; this is due to the instability 
of diacetic acid, and at once differentiates the latter from other substances, 
such as salicylic acid, antipyrin acetates, and carbolic acid, which give a 
similar reaction, but which does not disappear on boiling. 

When there is any doubt concerning the nature of the reaction, some 
of the urine should be acidulated with sulphuric acid and shaken up 
with ether. The ether is removed with a pipette and shaken up with 
very dilute ferric-chloride solution; if diacetic acid is present, a violet 
color results, which changes to a Bordeaux-red upon further addition of 
ferric chloride. The presence of as small an amount of diacetic acid as 
0.01 per cent still giyes this reaction. 

,5-Oxybutyric Acid.— This acid (C 4 H H 3 ), with acetone and diacetic 
acid, constituted the acetone bodies; it is always associated with diacetic 
acid in the urine. It is present in advanced cases of diabetes, but has 



OTHER ABNORMAL CONSTITUENTS. 55 

also been found in scarlet fever, diphtheria, measles, scurvy, and 
other diseases. Its detection in urine is difficult and of little clinical 
value. 

Indican. — Indican, or indoxyl potassium sulphate (C b Ho^O.SO„K), 
is derived from indol, a product of intestinal putrefaction of albuminous 
substances. The indol is absorbed by the blood and oxidized in the tis- 
sues to indoxyl, which combines with potassium sulphate and is elimi- 
nated in the urine. Indigo blue is formed by the oxidation of indoxyl 
potassium sulphate. 

Indican is present in minute amount in every normal urine, about 
0.015 gm. being voided in twenty-four hours with a mixed diet; the 
amount is increased up to 0.06 gm. by a meat diet. In many patholog- 
ical conditions it may be considerably increased, and such an indicanuria 
is especially pronounced in all diseases in which increased albuminous 
putrefaction in the small intestine occurs. It is found in all gastro- 
intestinal disturbances, especially obstruction in the small intestine, 
in cholera, typhoid fever, tuberculosis of the intestines, peritonitis, 
cancer of the stomach, liver, and intestines, as well as in many other 
diseases. 

Its detection by Jaffe's method is the following: Pour into a test tube 
a small quantity of urine and mix with an equal amount of strong hydro- 
chloric acid; add ten or fifteen drops of chloroform and, drop by drop, a 
moderately strong fresh solution of chloride of lime, shaking after each 
drop. The chloroform readily dissolves the freshly formed indigo, and a 
blue color appears, which is more or less pronounced, according to the 
amount of indican present. 

Another good test is that of Obermoyer: Precipitate 20 c.c. of urine 
with 5 to 10 c.c. of a ten per cent lead-acetate solution and filter; add an 
equal volume of fuming hydrochloric acid containing 2 gm. of ferric chlo- 
ride to 1 litre of HC1; shake thoroughly and add 5 c.c. of chloroform; 
again shake. This extracts the indigo, and the blue chloroform solu- 
tion settles at the bottom of the test tube. With normal urine a 
faint blue color results, while an increase of indican gives a dark blue 
color. 

Ehrlich's Diazo Reaction. — The diazo reaction was suggested by 
Ehrlich as a valuable adjuvant in the diagnosis of typhoid fever. It is 
still used for this purpose to a limited degree, although it has been sup- 
planted in a great measure by the agglutination test applied to blood. It 
is not characteristic for typhoid fever, and is frequently enough absent 
in even pronounced cases of the disease ; when present, it usually disap- 
pears at the end of the third week, but may reappear in a relapse. 



56 URINARY ANALYSIS AND DIAGNOSIS. 

The solutions necessary for the reaction are two : 

1 . Diazo reagent : 

Sulphanilic acid, 0.25 

Hydrochloric acid, 12.5 

Distilled water, 250.0 

2. Sodium nitrite, 0.1 

Distilled water, 20.0 

These solutions keep best in dark bottles and must be kept sepa- 
rately. When needed, mix 50 c.c. of the diazo reagent with 1 c.c. of the 
sodium-nitrite solution. 

The test is performed by mixing 10 c.c. of the urine with 10 c.c. of the 
mixed reagents, quickly adding 2 c.c. of a ten per cent ammonia solution. 
If the reaction is positive the solution assumes a carmine- or deep cherry- 
red color, which also appears in the foam. A coffee-brown color is not 
indicative of a positive reaction. On standing for twenty-four hours a 
dark green precipitate is formed when the reaction is positive. 

The diazo reaction has also been found in measles, pneumonia, scarlet 
fever, erysipelas, typhus, puerperal septicaemia, syphilis, cancer, and 
especially tuberculosis ; in the latter disease the presence of the reaction 
is frequently an unfavorable sign, as it has been often found in cases with 
a rapidly fatal termination. 

Different drugs, such as opium, morphine, chrysarobin, naphthalin, 
and heroin, when taken internally give the diazo reaction, though here a 
green precipitate does not, as a rule, occur on standing for twenty-four 
hours. Other drugs, such as tannin, creosote, guaiacol, and salol, render 
the diazo reaction in urine negative — a point to be remembered in tuber- 
culosis, where a number of these drugs are frequently given. 

Coloring Matters. — Bile Pigments. — When biliary coloring matters ap- 
pear in the urine, the urine always has an abnormal color — dark yellow, 
brown, or greenish — and a yellow or yellowish-green froth or foam is pro- 
duced by shaking. In fresh urine bilirubin is usually found in combina- 
tion with alkalies; if allowed to stand exposed to the air, bilirubin be- 
comes oxidized to the green biliverdin, as well as to the less important 
oxidation products, biliprasin, bilifuscin, and bilihumin. When a consid- 
erable amount of the pigment is present is the urine, the morphological 
elements of the sediment often have a more or less pronounced yellow or 
brownish color. 

Bile pigments are met with in the urine in all cases in which there is 
an obstruction to the outflow of bile from the liver, and are seen in nu- 
merous pathological conditions of the liver, with or without the presence 



OTHER ABNORMAL CONSTITUENTS. 57 

of jaundice. They may, furthermore, appear as a result of blood changes 
and after hemorrhage into the tissues. 

The presence of biliary pigments in the urine can frequently be de- 
tected by the color of the urine and the foam, as well as by the yellow 
appearance of the elements in the sediment under the microscope. One 
of the best methods for detecting bile pigments in the urine is by Gm elm's 
test, which consists of placing a small quantity of strong nitric acid, con- 
taining a little yellow nitrous acid, into a test tube and gently floating a 
similar amount of urine upon it. If biliary coloring matters are present, 
a set of concentric colored rings will appear at the point of union between 
the acid and the urine; these rings, from above downward, will be green, 
blue, violet, red, and yellow, the green being the most predominant, and 
is indispensable in proving the presence of bile, the others being some- 
times more or less indistinct and even entirely absent. A moderate 
amount of albumin has no influence upon this reaction. 

A modification of this test by Rosenbach is also good: The urine is 
filtered through pure white filtering paper, and, after filtration, a drop of 
the acid is applied to the inside of the filter; around the nitric acid the 
same concentric rings will be observed. 

Another simple test is Ultzmann's: To 10 c.c. of urine add 3 or 4 c.c. 
of a twenty-five per cent caustic-potash solution and an excess of pure 
hydrochloric acid. If bile pigments are present, the mixture assumes a 
beautiful green color- 
Besides bile pigments, bile acids may be found in the urine with the 
pigments in pathological conditions of the liver. Their occurrence, how- 
ever, is rare and their detection of no clinical value. 

Coloring Matter of Blood. — Haemoglobin, the chief coloring matter of 
the blood, may be found in the urine, either enclosed in the red blood 
globules, in cases of hematuria, or in rare instances dissolved in the 
urine, the affection being called hemoglobinuria. When a small amount 
of blood is present in the urine, the color of the urine is not necessarily 
changed, and a slight cloudiness alone may or may not be found; when 
a large amount of blood is present, however, the color of the urine, as 
well as that of the sediment, is brown, reddish-brown, or red. 

Hematuria is common, may be due to many different causes, such as 
severe inflammations, concretions, calculi, tumors, traumatism, tubercu- 
losis, etc., and may occur from any portion of the genito-urinary tract. 
The source of the hemorrhage can be positively diagnosed only from the 
epithelia and other elements in the sediment under the microscope, as the 
macroscopic characteristics, from which it is claimed the source of the 
blood can be diagnosed, are in many cases entirely unreliable. 

Hemoglobinuria is due to a dissolution of the red blood corpuscles in 



58 URINARY ANALYSIS AND DIAGNOSIS. 

the blood-vessels, which permits the coloring matter to escape in solution. 
In this condition blood corpuscles are scanty or entirely absent; when 
present, they are quite pale and not easily recognized. Hemoglobinuria 
is occasionally found in severe infectious diseases, such as yellow fever, 
malignant smallpox, and scarlet fever; in extensive burns and after poi- 
soning with different substances, such as carbolic acid, phosphorus, and 
naphthol. Cases of paroxysmal hemoglobinuria also occur. 

The simplest method of detecting hemoglobin in urine is the boiling 
test: When urine is boiled and a few drops of acetic or nitric acid are 
added, the albuminous precipitate, always present in such cases, is 
not white, but has a more or less pronounced brown or brownish-red 
color. 

Heller's Test. — The earthy phosphates are precipitated from the 
urine b}^ the addition of caustic potash or soda and heat ; as they become 
precipitated they carry with them the coloring matter, and are therefore 
not white, but blood-red. Under the microscope the coloring matter can 
easily be detected whenever present in any form. 

Alme*ns' Guaiacum Test. — Thoroughly mix equal parts of tincture 
of guaiacum (1 part of guaiacum to 100 parts of absolute alcohol) and 
old oil of turpentine; upon this mixture, which must not have any blue 
color, layer the urine to be tested. If hemoglobin is present, first a blu- 
ish-green and then a light or dark blue ring appears at the point of con- 
tact; on shaking, the mixture becomes blue. Urine containing many 
pus corpuscles also gives a blue ring with this test, which, however, 
disappears on heating the mixture to the boiling point. 

Hamatoporphyrin, a derivative of hemoglobin, and urobilin, derived 
from bile and blood pigments, have been previously described. 

Melanin is a dark pigment of slight clinical importance, and is only 
rarely found in urine; it may occur in the urine of persons suffering from 
melanotic sarcoma or cancer, though it is not present in all cases of this 
kind, and has also been observed in different wasting diseases. The urine 
containing melanin is not usually dark when voided, but soon becomes so 
upon exposure to the air; upon the addition of oxidizing agents, such as 
ferric chloride, sulphuric acid, or bromine, the dark color appears more 
rapidly and intensely. Melanin is present in the urine as a chromogen — 
melanogen — which becomes oxidized to melanin. 

Fatty Matters.— In rare cases a varying amount of fat, rendering 
the urine more or less turbid, may be found. Such a condition, in which 
the fat is present either in a state of minute subdivision or in the form 
of larger oil drops, is called lipuria when no albumin is present, or chyl- 
uria when a large amount of albumin is found with an abundance of 



OTHER ABNORMAL CONSTITUENTS. 59 

small fat globules. In both lipuria and chyluria, cholesterin, usually in 
small amount only, may be present in the urine. 

The addition of ether quickly dissolves the fat, and the urine becomes 
clear. The microscope will reveal the presence of fat and cholesterin at 
once. 

Leucin and ty rosin are products of decomposition of the albumins. 
They usually occur together in the urine and are mostly found in rapidly 
destructive processes of the liver, such as acute yellow atrophy and phos- 
phorus-poisoning, although occasionally seen in other diseases. They 
can easily be detected by microscopical examination. 

Cystin. — Cystin (C 6 H 12 N a 4 S 2 ) occasionally appears in a number of 
members of the same family. It is not a normal ingredient of urine, and 
its chief clinical significance lies in its tendency to form calculi. Urine 
containing cystin may have a peculiar odor, a greenish-yellow color, and 
develops the odor of sulphureted hydrogen upon standing; a grayish- 
white precipitate may form. When cystin is present, certain products of 
intestinal putrefaction, the diamins, especially cadaverin and putrescin, 
are almost constantly found. The neutral sulphur of the urine is greatly 
increased in amount in these cases of cystinuria. Cystin is soluble in am- 
monia and can be precipitated by acetic acid. Its microscopical appear- 
ance is quite characteristic. 



PART SECOND. 

MICROSCOPICAL EXAMINATION. 



PART SECOND. 

MICROSCOPICAL EXAMINATION. 



CHAPTER VIII. 

GENERAL CONSIDERATIONS. 

Microscopical examination of urine is in many cases of greater diag- 
nostic importance than chemical examination, and should in every in- 
stance form a part of urinary analysis. Whenever possible, urine, before 
it is to be examined under the microscope, should be set aside in a well- 
stoppered bottle or conical vessel, preferably in a cool place, for at least 






Fig. 14. — Sedimentation Glass. 



Fig. 15. — Spaeth's Sedimentation Glass. 



six> but better twelve, hours. If a conical vessel is selected, either a plain 
sedimentation glass (see Fig. 14) or Spaeth's improved sedimentation 
glass (see Fig, 15) may be used. The latter has a perforated stopper at 
the bottom, "and offers advantages over the ordinary form, in that the 
sediment is collected in, the stopper and can be removed with it, At the 
end of this time it will be seen that in every urine, even if perfectly nor- 
mal, a sediment has appeared at the bottom of the bottle, which is to be 
used for microscopical examination. This sediment in normal urine will 
be in the form of a cloudy deposit, the nubecula, and consists of mucus, 
flat epithelia from the bladder and vagina, and a varying number of epi- 

63 



64 



URINARY ANALYSIS AND DIAGNOSIS. 



dermal scales from the genital organs. Spermatozoa may be present in 
both male and female urine after sexual intercourse, and in the former 
after nocturnal emission. The sediment of normal urine may, further- 
more, contain even a large number of salts 
in the early morning, when the urine is highly 
concentrated, while these salts may be almost 
entirely absent at other times. 

After standing for some time, every urine 
undergoes a change, the rapidity of which 
depends upon the temperature as well as 
upon the degree of the reaction when passed. 
An acid urine, which is perfectly clear when 
passed, may become turbid upon cooling, 
owing to the presence of a large amount of 
urates. Micro-organisms, especially of the 
class of hyphomycetes or mould fungi, and 
saccharomycetes or yeast fungi, may sooner 
or later develop, and in a small degree 
schizomycetes, or fission fungi. A neutral 
or even slightly alkaline urine may be clear 
when voided, but soon becomes more or 
less cloudy, the change depending partly 
upon the salts, but mostly upon the development of bacteria belonging 
to the class of fission fungi. This change takes place quickly in warm 
weather, and is, as a rule, more pro- 
nounced in the urine of females than in 
that of males, on account of the bacteria 
which are normally found in the vagina. 
In pathological conditions the sedi- 
ment in the urine is usually more or 
less increased, though in mild cases the 
increase is not pronounced. In severe 
inflammatory or suppurative processes, 
however, it may be very abundant, 
this being due to pus corpuscles, blood 
corpuscles, epithelia, casts, etc., which 
it contains. Frequently such urine is 
cloudy when voided, and, when an ex- 
cessive amount of mucus is present, is fig. 17. 
ropy in character. 

Use of Centrifuge. — To overcome the necessity of waiting for pre- 
cipitation to take place and to avoid the changes due to decomposition 




Hand Centrifuge. 




iHiiili^ 

Water-power Centrifuge, 



GENERAL CONSIDERATIONS. 



65 






the centrifuge is considerably used. With this instrument three minutes 
are sufficient to obtain a proper sediment. The simplest centrifuge is 
operated by hand (see Fig. 16). Single-speed instruments give a speed 
of 3,000 revolutions a minute; double-speed instruments, 3,000 to 10,000 
revolutions. The former answers all ordinary purposes. The water- 
power centrifuge (see Fig. 17) is also easy to operate, giving a smooth 
and rapid motion; ordinary water pressure is sufficient to obtain the de- 
sired speed. Where electricity is obtainable, the 
electric centrifuge is the most satisfactory. The 
sedimentation tubes, supplied with the instru- 
ment (see Fig. 18), are either plain or gradu- 
ated, and hold 15 c.c. The instrument un- 
doubtedly has its advantages, but in many cases 
it is better to adhere to the old method and 
wait for six hours, the only precautions neces- 
sary being to keep the bottle tightly corked and 
in a cool place. 

One of the chief advantages of the cen- 
trifuge is that bacteria are thrown down in 
large numbers, so that the search for them is 
more successful. This is especially important 
in cases of suspected tuberculosis, as tubercle 
bacilli are found more readily in centrifuged 
than in non-centrifuged urine. 

On the other hand, the great force necessary 
to effect sedimentation will undoubtedly change 
some of the minute elements to a greater or less 
degree. Some of the pus corpuscles may assume different shapes, irregu- 
lar in character, partly due to commencing disintegration. These changes 
are not present in the non-centrifuged specimen, while the number of 
corpuscles is the same in both. Similar changes may take place in differ- 
ent epithelia as well as in spermatozoa, which latter may assume peculiar 
forms after the use of the centrifuge. When a proper sediment is ob- 
tained by standing, the number of casts in the centrifuged and non- 
centrifuged specimens is practically the same in a given case, though 
here, too, some may undergo changes by centrifugalizing. Mucus-threads 
are more abundant and more likely to take on the form of cylindroids, 
and this may be quite pronounced in healthy urines, in which no patho- 
logical features are present; these cylindroids often resemble hyaline 
casts to such a degree as to be easily mistaken for them. Extraneous 
fibres, such as linen fibres, easily break into minute fibrillse, and resem- 
ble connective-tissue shreds when the latter are not present. 
5 



~-J 



Fig. 18. — Sedimentation 
Tubes for Centrifuge. 



66 URINARY ANALYSIS AND DIAGNOSIS. 

When care is exercised in microscopical examination and only the 
perfectly distinct features are taken into consideration, the centrifuge 
may be used; but in most cases it cannot be considered superior to the 
old method. 

Mounting of Sediment. — The sediment having been obtained by 
either allowing at least four or six ounces of urine to stand at rest for the 
required time or by the use of the centrifuge, a drop of it is transferred 
to a slide for microscopical examination. For this purpose a glass pipette, 
consisting of a simple glass tube drawn to a moderately fine point at one < 
end, may be used. This tube is passed into the urine with the upper 
opening closed by one finger, until it almost touches bottom, when the ' 
pressure of the finger is gently relaxed, a small amount of the sediment 
from different layers drawn into the tube, the latter closed again with the 
finger, and withdrawn. A better method is carefully to decant the upper 
portion of the urine, pour the sediment into a small dish, and use a 
camel's-hair brush to transfer a drop to the slide. Such a brush can be 
thoroughly cleansed with water after each examination, and is kept clean 
more easily than a pipette. The drop of urine is put into the centre of the 
slide and a cover glass slowly dropped upon it, great care being taken not 
to press the cover down, since even the small amount of force used may 
be sufficient to change the epithelia or casts. Some workers never use 
cover glasses, but examine the urine upon the slide without covering it. 
This method is uncleanly and should never be employed. 

Use of Antiseptic Substances. — In order to avoid decomposition of 
the urine as much as possible, when it cannot be examined within twelve 
or twenty-four hours after being passed, large numbers of antiseptic sub- 
stances, such as salicylic acid, boric acid, chloroform, thymol, formalin, 
and bichloride of mercury have been recommended to be added in small 
amount to the urine; but when not absolutely necessary, it is better to 
avoid them. Of these substances thymol is the best, a small crystal being 
sufficient. The use of formalin should be avoided, as it is apt to change 
a number of the ingredients of the urine. Urine kept in a cool place and 
in a clean bottle can be examined, even thirty-six hours after being void- 
ed, without the danger of having to deal with too many putrefactive 
changes. In all cases the chemical analysis should be made as soon as 
possible. The sediment for microscopical examination can be mixed 
with a little alcohol if necessary, or, still better, chromic acid. 

Preservation of Sediment. — If it is desired to preserve a specimen 
for a variable length of time, the best method is to add from two to five 
drops of a five per cent chromic-acid solution to it; the only change that 
will take place is that the albumin becomes coagulated, appearing under 
the microscope in the form of irregular granular matter, irregularly scat- 



GENERAL CONSIDERATIONS. 07 

cred throughout the field. The chromic acid will preserve all the feat- 
ires permanently, not even causing any changes in the casts. Perma- 
nent microscopical or slide specimens are made by adding a few drops of 
jhemically pure glycerin to a small amount of the sediment previously 
seated with chromic acid, until a jelly-like mass is formed, and waiting 
'or a few days until all the superfluous water has evaporated. It is not 
tdvisable to add the glycerin to the sediment mixed with chromic acid 
intil the watery element of the urine has become evaporated, which will 
)e the case at the end of one or two weeks. If the sediment has become 
oo thick on account of the evaporation, a little more glycerin is added, 
drop then mounted upon a slide, a cover glass placed upon it, and the 
vhole surrounded by asphalt. Specimens preserved in this manner can 
>e kept for many years without change. 

Should it be desired to preserve a large amount of the urinary sedi- 
nent in a bottle, the chromic acid is added as before; but in that case it 
vill be better to add a larger amount of a weaker solution (about one- 
ourth or one-half per cent). After a few Weeks the upper part of the 
quid is poured off and a small amount of a forty or fifty per cent solu- 
ion of alcohol added, to prevent the growth of mildew. Microscopical 
pecimens can be made years afterward from urine so preserved, by tak- 
ng a drop of the sediment, mixing it with a drop of glycerin, and mount- 
ng upon a slide in the regular manner. 

Another method, which preserves the elements fairly well, consists in 
reating the sediment with equal parts of Kay em's liquid, composed of 
gm. of sodium chloride, 5 gm. of sodium sulphate, 0.5 gm. of corrosive 
ublimate, and 200 c.c. of water. 

Magnifying Powers. — Great difficulty is frequently encountered in 
eeing all the features present in a specimen of urine under the micro- 
cope, this being in many cases due to the want of a proper magnifying 
>ower. For the study of urine, the magnifying power should always be 
)etween 400 and 600 diameters, the average being 500. A good one-sixth 
Iry lens (make immaterial), together with a one-inch eyepiece, are all 
hat will be required. An Abbe condenser should not be used, except for 
he study of bacteria, nor will an immersion lens be always necessary 
ven then. Both tubercle bacilli and gonococci can be seen with a power 
)f 500 diameters if the specimen is well stained, although a somewhat 
ligher power, 700 to 800, which can be obtained by using a one-eighth 
Iry lens, is undoubtedly superior. Should it be desired to use an immer- 
sion lens for the study of bacteria, an Abbe condenser is essential. The 
Custom of trying to find casts with a lower power, 150 to 200 diameters, 
cannot be recommended, since it is impossible to recognize some of the 
)ther features present in the case with such a power, and there are many 



68 URINARY ANALYSIS AND DIAGNOSIS. 

cases of great importance in which no casts are present. In studying a 
case under the microscope, it will be found of great advantage to keep a ( 
record of all the features as they are found, and also to note their com- 
parative numbers. Sketches of the features will still further simplify the 
study. Too much stress cannot be laid upon the fact that, in the study 
of epithelia, the comparative sizes of corpuscles and epithelia can alone 
lead to correct diagnoses, so that the advantages of rough sketches can 
readily be appreciated. 



I 

j 



CHAPTER IX. 

CRYSTALLINE AND AMORPHOUS SEDIMENTS. 

The crystalline and amorphous or chemical sediments found in urine 
ire mostly the different acids and salts, though a number of other unor- 
ganized sediments may also be present. 

I. ACIDS AND SALTS. 

The salts which may be found under the microscope are seen partly 
n acid and partly in alkaline urine, and the sediments are the following : 

A. ACID SEDIMENTS. 

1. Uric acid 

2. Sodium urate 

(a) Amorphous y Common 
(6) Crystalline 

3. Calcium oxalate 

4. Cystin 

5. Creatinin [ 

6. Hippuric acid Y Rare. 

7. Leucin I 

8. Tyrosin J 

9. Calcium sulphate. — Very rare. 

B. ALKALINE SEDIMENTS. 

1. Triple phosphates or ammonio-magnesiaii 

phosphates 

(a) Complete 

(b) Incomplete 

2. Simple phosphates or calcium phosphates 

(a) Amorphous 

(6) Star-shaped, or stellate 

3. Ammonium urate 

4. Calcium carbonate. — Rare. 

5. Magnesium phosphate. — Very rare. 

A. ACID SEDIMENTS. 

1. Uric Acid.' — Uric acid is a constant ingredient of the urine, and is 
'requently seen under the microscope. Its amount is greatly increased 
3v an abundant proteid diet, such as meat, especially with diminished 

69 



>- Common. 



70 



URINARY ANALYSIS AND DIAGNOSIS. 



exercise or sedentary habits. It is also augmented in acute febrile dis- 
eases and in impeded function of the heart, lungs, and kidney. It is 
diminished by a diet poor in protein matters; also in chronic kidney dis- 




Fig. 19. — Crystals of Uric Acid, Common Form (X 400). 

eases and other diseases in which the amount of urea is diminished. The 
precipitation of a large amount of uric acid does not necessarily signify 
an increase in its elimination. 

Uric acid varies greatly in shape and size, and is of a yellowish-brown 
or reddish-brown color, except when precipitated in very thin plates, 
when its color is pale yellow, or it may appear almost colorless. Different 
varieties of uric acid are met with, some of which are frequently seen and 
constitute the common forms, while others are found more rarely. When 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 



71 



present in larger amount it becomes precipitated in the form of reddish 
masses, which adhere to the sides of the vessel and produce the so-called 
brick-dust sediment. These masses are known as gravel or sand. 

The common form of uric acid (see Fig. 19) consists of rhomboidal 
prisms — lozenge shape. The lozenges may be large or small, single or 




Fig. 20. — Crystals of Uric Acid, Common Form (X 400). 



multiple, with round or pointed ends, being at times more or less irregu- 
lar. There may be two lozenges together, giving the twin form, or they 
may be seen either half-edge or edgewise, or they may be in more or less 
regular barrels. Besides these, complicated formations, crosses, and ro- 
settes, are seen (see Fig. 20) , the latter being a conglomeration of lozenges, 



72 



UBINAEY ANALYSIS AND DIAGNOSIS. 



either in front view or edgewise, and frequently smaller crystals, some- 
times quite irregular, are found within the larger ones. 

Another form (see Fig. 21) is often seen in highly acid urine, and is 
usually found with gouty or rheumatic processes or with the formation 




Fig. 21. — Crystals of Uric Acid, from Highly Acid Urine (X 450). 

of uric-acid concretions in the bladder. These crystals appear in peculiar 
spear, comb, and brush shapes or in exaggerated lozenges. The spear 
shapes are in many cases very pronounced. In persons in whom the so- 
called uric-acid diathesis exists, these forms are frequently seen. 

Still another variety of uric acid (see Fig. 22) consists of concretions 
of varying sizes, irregular plates, masses, and needles, either single, 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 



73 



double, or conglomerated in the form of stars. Occasionally dumb-bell 
forms are also met with. The passage of such concretions or gravel 
proper, when at all abundant, is almost invariably accompanied by more 
or less severe pain. When in larger masses, we have the uric-acid cal- 




Fig. 22. — Uric-acid Coxcretioxs (X 500). 

culi or stones, which form the largest number of renal stones, being per- 
haps seventy per cent of all calculi passed. 

Quite frequently small, irregular plates of a light or dark yellow color 
are seen under the microscope; the sediment in which these are found 
may be of a mucous or granular character, which gives no indication of 
containing any uric acid. Different varieties of uric acid with calcium- 
oxalate crystals and occasionally a varying amount of urates are not in- 



74 



UBINABY ANALYSIS AND DIAGNOSIS. 



frequently met with in the same specimen. When these features are! 
present, the diagnosis of lithccmia is justified. 

Although in almost all cases there will be no difficulty in recognizing | 
uric acid under the microscope, there may be extremely pale, practically I 
colorless lozenges or irregular plates which might be mistaken for phos- I 

:i 




Fig. 23.— Pale Uric-acid Crystals (X 500). 

phates or imperfect calcium-oxalate crystals. In Fig. 23 pale crystals of 
different sizes and shapes are depicted. In order to ascertain their exact 
character, a small amount of some alkali, such as caustic potash or soda, 
may be added while the specimen is examined under the microscope, 
when the uric-acid crystals will be seen to dissolve readily. If now a 
drop or two of acetic acid be added, small characteristic crystals will 
soon reappear. 



CRYSTALLINE AND AMORPHOUS SEDIMENTb. 75 

2. Sodium Urate. — Sodium urate (see Fig. 24), when present in large 
amounts, forms the so-called clay-water sediment, which renders the urine 
turbid upon cooling. It may be found alone or in combination with 
uric acid and potassium urate, from which latter it can hardly be distin- 
guished. Such a sediment is the so-called sedimentum lateritium. Sodium 
urate usually consists of groups of light or dark brown, fine, amorphous 
granules in a moss-like arrangement, which easily adhere to foreign sub- 
stances as well as to mucus and epithelia. The groups vary greatly in 
size and are at times quite large. 

This salt is of common occurrence, and is found in all slight febrile 
derangements, after mental and physical exertion, in colds, catarrhs of 



f-w at- # ** »■••# ***** 




Fig. 24. — Sodium Urate, Amorphous ( X 500). 

the stomach and intestines, on the first day of menstruation, and in gen- 
eral malaise; and it may also occur in perfectly healthy individuals 
where the urine is highly concentrated. It is held in solution while the 
urine is warm, but quickly becomes precipitated upon cooling. It is the 
effete material of oxidation, the so-called materia peccans of old physicians. 
In rare cases sodium urate is crystalline (see Fig. 25), appearing in 
the form of needle-like clusters or arranged like sheaves of wheat, or of a 
fan-shape arrangement, pointed toward the centre, and broader toward 
the periphery. This sediment has been found in various conditions, such 
as diseases of the stomach and intestines, and in healthy individuals dur- 
ing prolonged physical exertion. The accompanying illustration was 



7G 



URINARY ANALYSIS AND DIAGNOSIS. 



taken from a case of dermoid cyst of the kidney, where the crystals oc- 
curred in large numbers with uric-acid crystals. 

Sodium urate frequently undergoes a change a few hours after the 
urine is voided, the length of time required for the change depending upon 




Fig. 25. —Sodium Urate, Crystalline (X 500). 



the temperature. The granules commence to change into small brown 
globules, which are either single or grouped in twos; the latter soon coal- 
esce and form small dumb-bells, which gradually enlarge (see Fig. 26). 
This has been spoken of as the first stage of the formation of ammonium 
urate, the ammonium urate in statu nascenti, and denotes a commencing 
transition of the original acid sediment into an alkaline. When the alka- 
line change is more or less complete, we have the fully formed globules 
of ammonium urate. 

3. Calcium Oxalate. — Calcium oxalate, when present in small or 
moderate amount in the urine, without an increase of specific gravity, 
has no clinical significance. Oxalic acid, normally present in all urine in 
small quantities, has a special affinity for calcium, and appears in the 
urine as calcium oxalate. It is frequently found after eating certain kinds 
of fruits and vegetables, such as apples, oranges, bananas, certain berries, 
grapes, tomatoes, rhubarb, asparagus, spinach, and turnips. 

It occurs in a variety of forms (see Fig. 27) , but it is always colorless 
and of a moderately high degree of refraction. The most common forms 
are those of quadrilateral octahedrons, greatly varying in size, with single 
or double lines running from one end of the crystal to the other, crossing 
each other in the centre and giving the characteristic so-called letter- 



CRYSTALLINE AND A3I0FPH0US SEDIMENTS. 77 

envelope shape; when they are seen edgewise the octahedral form is 
more marked. These regular forms often commence to break down, so 
that the lines become lost. A number of the crystals may be arranged 
together, either in twos, giving the twin form, or in groups of three, four, 
or more. With these we often see small, more or less regular squares or 
dot-like irregular formations, the so-called amorphous shapes. A number 
of small squares may combine together, giving concretions sometimes of 
large size, which are especially abundant under the microscope when cal- 
cium-oxalate calculi are present. They are often massed together upon 
mucus-threads or foreign substances. Besides these, there are rarer 
forms, consisting of more or less concentrically striated, highly refractive 
discs or barrel shapes, and of variously sized dumb-bells. The latter may 
assume large proportions, and are easily differentiated from the dumb- 
bell forms of uric acid or ammonium urate, by their being colorless. 

The common forms of calcium-oxalate crystals can hardly be mistaken 
for anything else, if it is borne in mind that they are always without color 
and of a moderate refraction. The small discs may be mistaken for red 
blood globules, but are of a considerably higher refraction than the latter. 
Although usually present in acid urine only, they may be found in neutral 







Fio. 26. — Granules of Sodium Urate Changing to Globules and Dumb-bells 
(X 500). 

or slightly alkaline urine in small amount. When the reaction of an orig- 
inally acid urine has become alkaline, they gradually disappear, while 
triple phosphates commence to develop. Should there be any doubt as 
to their character, they will be found to be insoluble in acetic acid, but 
soluble in hvdrochloric acid. 



78 



UEINABY ANALYSIS AND DIAGNOSIS. 



When calcium oxalate is present in the urine in large amount, with a 
high specific gravity, 1.024, 1.030, or even 1.040, it often denotes the 
existence of oxaluria. This affection, although very common, is fre- 
quently overlooked. It gives the symptoms of neurasthenia, dyspepsia, 




Fig. 27. — Calcium-ox al ate Crystals (X 500). 



melancholia, general malaise, headaches, and ill-defined pains in the 
lumbar region. Those afflicted are usually of sedentary habits and are 
accustomed to live well. In rare cases, especially when concretions of 
considerable size are present, hematuria, often severe and protracted, is 
a pronounced symptom. It may last for months, but its cause can at 
once be ascertained by an examination of the urine. As soon as the pa- 
tient's diet is regulated and he takes considerable outdoor exercise, the 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 



79 



oxalates decrease and the symptoms improve. With such cases inflam- 
mation of the pelvis of the kidney, and sometimes also of the kidney 
proper, though, as a rule, mild in character, is of common occurrence. 

4. Cystin. — Cystin is a comparatively rare sediment, but may pro- 
duce concretions in the bladder. It consists (see Fig. 28) of hexagonal, 
colorless plates of moderate sizes, of high refraction, which, in side view, 
present one perfect facet and two imperfect neighboring facets. A num- 
ber of plates may lie together, one upon another, or they may form more 
or less regular masses. It is readily soluble in ammonia, one of the feat- 
ures distinguishing it from uric acid. Cystin contains considerable sul- 
phur as a constituent. 

Cystin seems to occur in all members of certain families instead of 
uric acid; in such families it appears to replace uric acid, and in them 
cystin calculi are not rare. 

5. Creatinin. — Creatinin, normally present in the urine in very small 
amount, is found under the microscope in rare instances only. It consists 

C3° 




(see Fig. 29) of colorless prisms or plates, partly lozenge- and partly bar- 
rel-shaped. Frequently there are two, three, or even more plates, one 
within the other, or the plates may conglomerate in groups. Occasion- 
ally, more particularly when the urine has stood for some time, peculiar 
configurations appear in the interior of the plates. 



Fig. 28.— Cystin Crystals (X 500). 



80 



TJRINABY ANALYSIS AND DIAGNOSIS. 



Creatinin is found most frequently after prolonged muscular exercise, 
as is seen in athletes during active training. A rare sediment, found in 
the urine of a perfectly healthy athlete, is shown in Fig. 30. This sedi- 
ment contains plates and lozenges of creatinin, the rare crystalline form 




Fig. 29. — Creatinin Crystals (X 500). 



& 1IIM 
ill 



c^y 




W <t# 











y 



'W 



^ " ' JT ^g^ ^* ^ — * 

Fig. 30.— Sediment in the Urine of an Athlete ( X 500). 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 81 

of sodium urate, and peculiar formations, consisting partly of fan-shaped 
and partly of angular crystals, from which a varying number of long 
needles are seen to emanate. Some of these crystals resemble rarer forms 
of ammonium urate. 

Clinically, creatinin has been found in cases of severe acute paren- 




Fig. 31— Hippuric Acid (X 500). 

chymatous nephritis, associated with ursemic convulsions, and has also 
been seen in the urine in typhoid fever, pneumonia, and diabetes. 

6. Hippuric Acid. — Hippuric acid, which is present in all normal 

urine, is almost always held in solution, though it may be found in small 

amount after a vegetable diet and after eating certain fruits, such as 

ranberries, plums, and prunes. In the urine of herbivorous animals, 

6 



82 



URINARY ANALYSIS AND DIAGNOSIS. 



especially in horses, it is of common occurrence. It is found in larger 
amount after the administration of benzoic acid or one of the benzoates, 
salicylic acid, cinnamic acid, and oil of bitter almonds. It has also been 
seen occasionally in diabetes. 

It consists (see Fig. 31) of variously sized, colorless prisms and plates, 
often conglomerated into larger or smaller masses. The plates may be 




Fig. 32. — Leucin and Tyrosin (X 500). 

thin and extremely long, at times resembling needles. Hippuric acid 
might occasionally be mistaken for some forms of phosphates, but can 
easily be differentiated from them by its insolubility in acetic acid. 

7, 8. Leucin and Tyrosin. — Leucin and tyrosin are rare sediments,, 
and usually occur together. They are never seen in normal urine, bu1 
mostly in severe acute and usually fatal diseases of the liver, such as 






CRYSTALLINE AND AMORPHOUS SEDIMENTS. 



83 



1 acute yellow atrophy of the liver, phosphorus-poisoning, and in yellow 
fever. They have also been found in cases of smallpox, scarlet fever, and 
typhoid fever. 

Leucin (see Fig. 32) appears under the microscope in the form of flat, 
yellowish or brown globules of different sizes, with delicate radiating and 
oncentric striations. Tyrosin is found in the form of needle-shaped 
rystals, grouped in clusters or sheaves, crossing at various angles. 

Both leucin and tyrosin somewhat resemble fat, the former the fat- 
lobules, the latter the needles of fat — so-called margaric acid — but differ 
rom fat by being insoluble in ether. 

9. Calcium Sulphate. — Calcium sulphate (see Fig. 33) occurs in 




Fig. 33. — Calcium-sulphate Crystals (X 500). 

rine in a small number of cases only, the specific gravity of the urine 
eing, as a rule, high. It consists of thin, colorless prisms or needles, 
ther single, in groups, or in rosettes, resembling crystalline calcium 
hosphate, but more regular. Its clinical significance is not known. 



aci 



B. ALKALINE SEDIMENTS. 



1. Triple Phosphates. — Triple phosphates, the combined ammonio- 

lentliagnesian phosphates, may be divided into complete and incomplete. 

,bu hey may be found under the microscope in small numbers in urines 

hich still give a faintly acid reaction, but invariably denote a change to 



84 



URINARY ANALYSIS AND DIAGNOSIS. 



alkalinity. When present in large numbers, the urine is always alkaline, 
These phosphates are frequently secondary formations, not being seen 
when the urine is freshly voided, but being found in varying numbers- a 
few hours later. They may be seen to develop while the urine is exam 







Fig. 34.— Complete Triple Phosphates (X 500). 

ined under the microscope. As all urates are colored to a greater or les 
degree, all phosphates are invariably colorless. 

^ Complete triple phosphates (see Fig. 34) are colorless, triangula 
prisms or rhomboidal crystals, highly refractive, with bevelled ends— th! 
so-called coffin-lid shapes. They vary greatly in size and shape, the lattc 
being different when the crystals are seen in front, side, or top vie? 



pete 



Ukj 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 



85 



Some of the smaller ones can hardly be differentiated from calcium oxa- 
late crystals. 

Incomplete triple phosphates (see Fig. 35) are seen in many forms and 
sizes. It seems that these crystals are in part not yet fully developed 
(especially the smaller varieties, which may in time grow and become 




Fig. 35. — Incomplete Triple Phosphates (X 500). 

complete), and in part have become broken down from previously com- 
plete forms. All the different transitions can be seen in the same speci- 
' ll men when it is studied on two or three successive days, which can easily 
A be done by simply adding a drop of glycerin to the urine upon the slide. 
161 The incomplete forms represent irregular plates, either without any dis- 



86 URINARY ANALYSIS AND DIAGNOSIS. 

tinct marks or with irregular lines, the result of the transformation of the 
complete crystals. The crystals may be broken down in the centre, or 
there may be peculiar cross-like formations, or even irregular star-shaped 
crystals, which can be likened to a fern leaf. 

Triple phosphates may be found in varying numbers in normal urine 
after a vegetable diet. Their amount is increased in chronic inflamma- 
tory conditions of all kinds, in rheumatic processes, in inflammation of 
the bones, and in diseases of the nerve-centres. They are especially abun- 
dant in cases of chronic cystitis, where an alkaline putrefaction of the 
urine takes place in the bladder, and may be precipitated in large, flaky 
deposits, the urine having a pronounced ammoniacal odor. 

2. Simple Phosphates. — Simple phosphates, or calcium phosphates, 




0° • OOO eO'.-V.J'o! %' * ••• . % ° it 

• ° * ° ° ° "" oo ° o J o " o ' '" ° '" 






'ooo ■ ..* ': l°°°°'° ; '°° "° h °" '•'• ° ( 



0* " O' ° 
,00°., 



o- 0> 



t v O v * V Q O 9 V 9 Q0 -W» ff Q 




Fig. 36. — Amorphous Simple Phosphates (X 500). 

are of two distinct varieties: first, amorphous; and second, star-shaped 
or stellate. 

Amorphous simple phosphates (see Fig. 36) appear in the form of 
colorless globules or granules, of a moderate refraction, either single or 
clustered together in variously sized groups, but never in a moss-like 
arrangement, as the sodium urate. These phosphates are abundantly 
found after a milk diet, as well as after drinking different alkaline min- 
eral waters. 

Star-shaped or stellate simple phosphates, although of less frequent 
occurrence than the other variety, are by no means rare, and are often 
found in conjunction with the triple phosphates. They consist (see Fig. 
37) either of slender, colorless rods or of pointed spicules of various sizes, 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 



87 



at times larger and smaller ones being found together. Although they 
may be found single, their characteristic grouping is in the form of stars 
or rosettes, more or less complete. The spicules, of which the rosettes 
are composed, are united in the centre of the rosette, while each spicule 




Fig. 37. — Star-shaped Simple Phosphates (X 500). 



may have a uniform diameter or be broadened at the periphery and nar- 
rowed in the centre. 

Much has been written about the significance of the phosphates in the 
urine, and great stress has been laid upon their continual increase or 
diminution, the latter being said to be of constant occurrence in cases of 
nephritis. It is an undeniable fact that the phosphates are diminished 



88 



URINARY ANALYSIS AND DIAGNOSIS. 



in severe and usually advanced cases of nephritis, but not more so than 
the other salts, there being a pronounced decrease of all salts in such j 



cases. 



In rare cases there is a continual increase of the phosphates in the 
urine, without any apparent cause. Such cases have been designated by 
the term phosphahiria , and they may give similar symptoms to those of 
oxaluria. The phosphates precipitating in the urine being frequently 




Fig. 38. — Ammonium Urate (X 500). 

secondary formations, such a diagnosis must only be made when their 
amount is found to be greatly increased immediately after the urine is 
voided, and the presence of inflammatory conditions of any kind in the 
body can be excluded. A change of diet will often rectify this trouble in 
a short time. All phosphates are easily soluble in acetic acid, which will 
quickly clear up any doubts as to their character. 

3. Ammonium Urate. — Ammonium urate is a common sediment in 
alkaline urine, especially in connection with triple and simple phosphates, 
and is seen in fresh urine only when it is passed in an alkaline condition. 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 



89 



It is the result of alkaline decomposition. It appears (see Fig. 38) in the 
form of brown globules of various shapes and sizes, usually exhibiting 
pronounced concentric and radiating striations. The globules may ap- 
pear singly or in clusters, sometimes forming large, coalesced masses. 
They are either smooth or provided with thorny, sometimes branching 



o o o o o 




Fig. 39. — Acid Sediment in Fermentation and in Transition to Alkaline (X 500). 
U, Uric-acid plates ; UN, uric-acid needles ; US, sodium urate in transition to globules 
and dumb-bells; UA, ammonium urate; O, calcium oxalate; C, conidia; M, mycelia. 

and curved offshoots — the so-called thorn-apple shapes. The offshoots 
vary greatly in size and number, there being either one or many upon a 
single globule. Not infrequently the globules, especially the smaller ones, 
conglomerate so as to form concretions, sometimes of large size, and this 
may also be the case when mucus-threads or foreign substances, such as 



90 URINARY ANALYSIS AND DIAGNOSIS. 

cotton or linen fibres, are present. Upon the addition of hydrochloric 
acid the globules of ammonium urate disappear and small rhombic crys- 
tals of uric acid are formed. Ammonium urate is soluble in alkalies, by 
the addition of which an odor of ammonia is evolved. 

The alkaline change, which may take place in an originally acid urine, 
is illustrated in Fig. 39. When the urine was voided it contained nothing 
but a large number of uric-acid crystals of different forms, both plates 
and needles, some groups of sodium urate, and crystals of calcium oxa- 
late. After about twelve hours fermentative changes commenced to ap- 
pear, and fungi, in the form of conidia and mycelia, developed. The 
sodium-urate granules were now found to have partly changed into small 
globules and dumb-bells, possibly the first formed ammonium urate. 



o ' 













Fig. 40. — Calcium Carbonate and Magnesium Phosphate (X 500). 

This change gradually continued until larger globules of ammoniun 
urate, as well as more irregular forms, had developed. Triple phosphates 
were not seen in this specimen. 

4. Calcium Carbonate.— Calcium carbonate is a comparatively rare 
alkaline sediment, occurring either alone or in combination with the 
phosphates. It is usually found (see Fig. 40) in the form of amor- 
phous granules and globules of different sizes, though mostly larger thai 
the globules of amorphous simple phosphates; they are seen either singl} 
or in groups of varying sizes, and are of very high refraction. Occa- 
sionally dumb-bell forms are also present, and very rarely small delicate 
prisms. By adding an acid, such as acetic acid, effervescence is pro 
duced, which also occurs in the presence of ammonium carbonate, thougl 



fttrai 
and oj 
life, 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 



91 



this is always held in solution and never seen under the microscope. Cal- 
cium carbonate is the most common sediment in herbivorous animals, 
and the turbidity of their urine is due to its presence. 

This salt appears mainly in inflammatory and carious processes of the 
bony system, such as osteitis, osteomyelitis, osteomalacia, and rhachitis. 
It may also be found in diabetes and phthisis. After drinking certain 
mineral waters in large quantities it may be seen in the urine. 

5. Magnesium Phosphate.— Magnesium phosphate (Fig. 40) is an 
extremely rare sediment, producing colorless, highly refractive, elongated, 
quadrilateral prisms, sometimes resembling the small plates of incom- 
plete triple phosphates. It is observed in the urine after the internal use 
of the fixed alkali-carbonates, such as are held in solution in many min- 
eral waters, and may be found with calcium carbonate. It is readily 
soluble in acetic acid. 

II. OTHER UNORGANIZED SEDIMENTS. 

Eat. — Fat, in the form of globules and granules, is of common oc- 
3urrence in the urine, but care must be taken not to confound it with 




O 
o 

>9loyo 

0°ofSo 

Fig. 41. — Fat-globules and Margaric-acid Needles (X 500). 



iatt 

raj 
t 

ttlOf 

thai 

A extraneous fat-globules, which in many cases are larger, more irregular, 
)ccl tnd of a more yellowish color. If fat is not present in too large quan- 
ical ities, the microscopical appearance of the urine is not changed, but if it 
pro exists in large amount, as, for instance, in the rare cases of chyluria, in 
0112I ;onnection with considerable albumin, the urine is turbid or milky when 



92 URINARY ANALYSIS AND DIAGNOSIS. 

voided, and, after standing, a peculiar creamy layer appears at the top 
of the urine. When fat-globules are voided in such large quantities as to 
be seen with the naked eye, and albumin is either entirely absent or 
present in small amount only, the diagnosis lipuria is justified; these 
cases are, however, just as rare as those of chyluria. The addition of a 
few drops of ether clears up the urine to a certain degree. 

Fat-globules and -granules vary considerably in size (see Fig. 41). 
When the larger globules are found, needles of margaric acid may also be 
present; these are long, slender formations, in which a double contour 
can be seen only in rare instances. They lie between the globules, as well 
as within them in some cases, and may also appear to emanate directly 
from them. Fat-globules have a high refraction and usually a rather 
dark contour. 

Leaving out of consideration the rare cases of chyluria and pronounced 
lipuria, the latter of which has been observed in healthy individuals tem- 
porarily after a highly fatty diet, as well as in. pregnant women and in cases 
of phosphorus-poisoning, the appearance of a small or moderate number 
of small fat-globules and -granules, either singly or in variously sized 
groups, is seen in all cases in which a chronic inflammation, even of mild 
character, exists somewhere in the geni to-urinary tract. These globules 
are not only found lying free throughout the different fields, but in vary- 
ing numbers within the epithelia and pus-corpuscles, being undoubtedly 
secondary products of the protoplasm. The globules may make their 
appearance in small numbers a few weeks after the commencement of 
the inflammation, but are found in greater quantity only in chronic cases ; 
the more numerous the globules, the more pronounced the inflammation. 
At first, one or two glistening globules of very small size are seen in the 
granular protoplasm, which condition becomes more and more pro- 
nounced, until the fatty degeneration, in severe cases, attacks the whole 
of the epithelium, occasionally changing its appearance completely. 

Such fat-globules are, therefore, found not only in chronic cases of 
nephritis and pyelitis, but also in cystitis, prostatitis, urethritis, and vag- 
initis. In the different varieties of nephritis their numbers vary greatly. 
When present in small or moderate numbers only, no other diagnosis 
than that of a chronic inflammation is justifiable; but if very abundant, 
either with or without the presence of fatty casts, a diagnosis of fatty de- 
generation can be made. 

Cholesterin. — Cholesterin, a normal Ingredient of bile, is occasion- 
ally found in the urine. It consists (see Fig. 42) of colorless, thin, irregu- 
lar rhomboidal plates, frequently broken in different parts and of greatly 
varying sizes. It easily dissolves in ether, and takes on a reddish or vio- 
Ie1 color if treated with iodine and a drop of a sulphuric-acid solution. 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 



93 



Cholesterin has been found in a few cases of chronic cystitis, in rare 
cases of chronic parenchymatous nephritis with fatty degeneration, and 
in chyluria. Its exact significance is unknown. 




Fig. 42. — Cholesterin Crystals ( X 400). 




Fig. 43.— H^ematoidin Crystals ( X 500). 



Haematoidin. — Harnatoidin crystals seem to be the result of extrav- 
asated blood, if retained within the tissues. They appear in the urine 
(see Fig. 43) in the form of small, irregular plates, as well as needle- 



94 URINARY ANALYSIS AND DIAGNOSIS. 

shaped, sometimes stellate, crystals of a reddish-brown or, rather, rust- 
brown color. The needle-shaped crystals vary considerably in size, and 
may be found either singly or in conglomerations of peculiar forms. Not 
only may the needles be arranged so as to form bunches resembling the 
bristles of a brush, but an irregular mass may be surrounded by a large 
number of needles, sometimes giving a crab-like appearance. The larger 
formations are rare, while the smaller are comparatively common, not 
only lying free, but also in the interior of pus corpuscles and epithelia. 
Their presence always denotes a hemorrhage which has taken place at 
some previous time, and they may, therefore, be found in a variety of 
different lesions. 

Besides hsematoidin, it is claimed that bilirubin may be found under 
the microscope, closely resembling the crystals of haBmatoidin, and seen 
in both plate and needle form. They are usually larger and more irregu- 
lar than the former, and their relationship is still undecided. 

Indigo. — All normal urine contains a small amount of indican, and 
the indigo occasionally found in the urine is, as a rule, a secondary prod- 




/# h*.K 



Fig. 44. — Indigo Crystals (X 500). 

uct of oxidation, often seen when putrefactive changes have developed. 
In rare cases the urine has a bluish color when voided, the indigo having 
been formed in the body; this is seen in pathological conditions only. 

Indigo (see Fig. 44) is seen in the form of blue rhomboidal crystals of 
small size, or irregular masses, as well as in needles and thin plates. Al- 
though it was formerly always considered to have a pathological signifi- 
cance, it is now known to be present in perfectly normal conditions. It 
is not uncommon to see indigo under the microscope in small amount as 
extraneous matter from the underwear, and this cannot, in most cases, 
be distinguished from that formed in the urine. 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 95 

Melanin. — Another coloring matter which at times is seen in the 
urine is melanin, appearing as dark brown or perfectly black, irregular 
granules or masses of small size. It has been found in melanotic tumors, 
uch as sarcoma and cancer, as well as in broken-down constitutions 
due to various troubles, and cannot be said to have any special sig- 
nificance. 

URINARY CONCRETIONS. 

Quite frequently concretions may form in the urinary passages and 
be found in the urine. When very small, these concretions are called 
gravel; when large, stones or calculi. The former can be passed in large 
amount with little or no pain; the latter cause great suffering and the 
condition may require surgical interference. Concretions are formed 
ither in the kidney, pelvis of kidney, or bladder, and most frequently 
3onsist of uric acid, urates, calcium oxalate, or phosphates. Besides 
these, concretions of cystin and calcium carbonate, as well as indigo and 
^;anthin, may be found. 

Concretions may consist of one ingredient only, or of two or more in 
alternate layers. The majority of concretions have a central portion or 
mcleus and a peripheral portion or body. The nucleus varies in size and 
omposition. It may consist of the same material as the body, though, 
is a rule, some organic product, such as a blood clot or mucus-thread, will 
orm the nucleus, around which the body of the calculus forms. In rare 
;ases, foreign bodies introduced into the bladder from outside become the 
mclei of stones. 

The most common are the uric-acid concretions, which may be passed 
n large amount in the form of gravel, but often attain a large size. They 
compose from seventy to eighty per cent of all concretions, and are 
"ormed either of uric acid alone or combined with the urates; are hard, 
and have a yellowish-brown or reddish-brown color. Calcium-oxalate 
3oncretions have a grayish or dark color, and may be either small, round, 
and smooth — called hemp-seed calculi — or large, rough masses — the mul- 
oerry calculi.- Sometimes the nucleus of these concretions consists of 
uric acid. Phosphatic concretions are usually formed of mixed triple 
phosphates and calcium phosphates. They are mostly of large size and 
have a grayish-white color. Other concretions are of rare occurrence. 
En many cases their nature can easily be determined by placing a minute 
oarticle in a drop of glycerin under the microscope. 

Although the presence of concretions, even when very minute, can 
almost invariably be determined by microscopical examination of the 
urine, a number of examinations must not infrequently be made before 
the diagnosis becomes positive. The first urine examined may contain a 



96 URINARY ANALYSIS AND DIAGNOSIS. 

small number of salts only, or these may be entirely absent under thji 
microscope, though subsequent examinations will show them in larg, 
amount and clear up any doubt. In all such cases inflammations o] 
hemorrhages from the kidney, pelvis of kidney, or bladder will sooner oi 
later develop. 

For a more detailed analysis, the concretions should be powdered and 
subjected to a red heat upon platinum foil. If the odor of hydrocyanic 
acid is given off, the concretion contains either uric acid or xanthin, the 
latter of very rare occurrence. Uric acid gives the characteristic murex- 
ide test; xanthin does not. If considerable residue of ash is left, which 
when heated to a high temperature melts to a white mass, it contains 
phosphates; phosphatic concretions are soluble in hydrochloric acid with- 
out effervescence. If the powder first blackens upon heating, but upon 
further heating leaves considerable white ash, which dissolves in hydro- 
chloric acid with effervescence, it contains calcium oxalate; if this solu- 
tion is neutralized with ammonia, and oxalic acid is added, characteristic 
envelope-shaped crystals, which are readily recognized under the micro- 
scope, are precipitated. If the powder upon burning emits an odor of 
sulphurous acid and burns with a bluish flame, it contains cystin; when 
ammonia is added to the powder it dissolves, and upon evaporation crys- 
tallizes in hexagonal plates easily diagnosed by the microscope. Calcium- 
carbonate concretions dissolve in hydrochloric acid with effervescence. 
In order to ascertain if a calculus consists of more than one ingre- 
dient, it is best to section it and examine the powder from each layer sep- 
arately. 



i 



ai'i 



r 



rei 



CHAPTER X. 

BLOOD-CORPUSCLES AND PUS-CORPUSCLES. 
I. BLOOD-CORPUSCLES. 



Red blood-corpuscles or -globules are of frequent occurrence in the urine ; 
hey may be derived from any portion of the genito-urinary tract. When 
•resent in small numbers, the color of the urine is either not changed or 
)Jt is cloudy; but when they occur in large numbers, the urine has a red- 
ish hue and may be of a dark red color. During the period of men- 
truation red blood corpuscles occur normally in the urine of females, but 
nth this exception their appearance invariably indicates some abnormal 
ondition. 

Red blood-corpuscles, as found in the urine, vary considerably in ap- 
>earance, shape, and size (see Fig. 45). In fresh urine they are discoid 
>odies of a yellowish hue and frequently crenated, but after a few hours 
inly may have entirely lost their haemoglobin and are then practically 
olorless. This, change takes place more quickly in alkaline than in acid 
irine, and also depends upon the degree of concentration of the urine. 
Ls long as the blood-corpuscles contain considerable hsemoglobin, they 
lave a yellowish color; as soon as they commence to lose their coloring 
natter, a double contour can usually be seen, the interior being in most 
sases apparently structureless. This is the condition in which they are 
nost frequently found. 

When they are present in large numbers, they are found both singly 
md conglomerated in variously sized masses, and the so-called thorn- 
ipple shapes are often seen. When they lie edgewise they appear biscuit- 
shaped, and may be found in small masses like rolls of coin; the latter is 
comparatively rare in urine. As a rule they are neither granular nor nu- 
cleated, and can thus easily be distinguished from pus-corpuscles, even if 
he double contour is not well marked. In acid urine, however, after it 
las been standing a few days, a small number may appear granular. 

Unless blood-corpuscles are present in very small numbers only, every 
irine containing them will also contain an appreciable amount of albu- 
min. In severe cases of haematuria the amount of albumin may reach 
zme-half of one per cent or more, and still the kidneys be perfectly nor- 
mal, the blood coming perhaps from the bladder, the urethra, or the 
Drostate gland. 

7 97 



98 



URINARY ANALYSIS AND DIAGNOSIS. 



When the urine is of a low specific gravity, the red blood-corpuscles 
frequently swell and become hydropic. In such cases they are large, pale, ; 
double-contoured bodies, and are called "ghosts." In an active hemor- 
rhage, besides the corpuscles described, small globules are frequently 




Fig. 45. — Blood-corpuscles ( X 500). 

seen, which are sometimes less than half the size of the regular corpuscles, 
but perfectly characteristic. These are of recent formation, are in proc- 
ess of growth, and may be called haematoblasts. 

Whenever a large number of red blood-corpuscles is present in the 
urine, a small number of white blood-corpuscles or leucocytes is invariably 
seen. They vary in amount, but average one of the latter to five hun- 
dred or six hundred of the former. Leucocytes cannot be distinguished 
from pus-corpuscles. They are usually found in the form of globular 
granular bodies, though they may easily change their form on account of 
the contractility of their protoplasm. When a hemorrhage exists and 
these corpuscles are seen in small numbers only, they should not be 
called pus-corpuscles. 

In an active hemorrhage we frequently notice, besides blood-corpus- 
cles, fibrin, as well as clots of blood (see Fig. 46). 

Fibrin appears either in the form of thin, pale, colorless strings, oi 
larger, more or less reddish or brown masses, frequently giving off smallei 
branches. It always consists of wavy bands, of a higher refraction at the 
periphery than in the centre, and of a characteristic appearance. Wheu 1 
large, the masses can easily be seen with the naked eye. In rare cases 



BLOOD-CORPUSCLES AND PUS- CORPUSCLES. 99 

such as severe hemorrhages due to tumors or parasites, they may attain 
enormous size, and not infrequently form regular casts. 

Blood-clots consist of irregular, rust-brown or dark masses, varying in 
size, which are composed of disintegrated blood-corpuscles ; they may be 
so dense that their structure cannot be made out, and they must be 
diagnosed from their color. 

When blood-corpuscles, even in small numbers, are present in the 
urine, it is absolutely essential to discover their source. This can only be 
determined by the nature of the epithelia in the urine. As long as the 
hemorrhage is mild or of moderate severity only, epithelia can always be 
found without any difficulty ; but in the worst cases of hgematuria, where 
many fields of the microscope may be crowded with blood-corpuscles, it 
is at times quite difficult to find epithelia. In these cases many drops of 
urine must sometimes be examined before the source of the hemorrhage 
can be positively determined. Some authors advise the removal of the 
blood from the sediment by the addition of a large amount of lukewarm 
water and a few drops of dilute acetic acid, stirring thoroughly and allow- 




Fig. 46. — Fibrin and Blood-clot (X 500). 

ing to settle. T.his process undoubtedly changes many of the other ele- 
ments present in the sediment, and it is best not to use it unless absolutely 
necessary. The color, reaction, and specific gravity of the urine, as well 
as the nature of the hgematuria, can never afford any positive clew as to 
the source of the blood. 



100 URINARY ANALYSIS AND DIAGNOSIS. 

The pathological conditions in which blood-corpuscles are found are 
numerous. They are present in small or moderate numbers in every 
acute inflammation, whether of mild or severe character, and even in sim- 
ple irritations and hyperemia. They will be found in a prostatitis as 
well as in a nephritis; also in pyelitis and cystitis. The presence in the 
urine of an abnormally large amount of salts may be sufficient to set up 
an irritation of the kidney or pelvis, with the appearance of blood-cor- 
puscles. 

Hemorrhages from the genito-urinary organs are of comparatively 
frequent occurrence and due to many causes. Perhaps among the most 
frequent of these cases are hemorrhages from the pelvis of the kidney, 
often due to gravel or calculi. Severe inflammations, abscesses, ulcers, 
tumors, stricture of the urethra, or traumata of different kinds, as well as 
parasites, will cause them. A little care exercised in discovering all the 
features present in the urine will in most cases lead to a positive diagno- 
sis of the source of the hematuria. 



II. PUS-CORPUSCLES. 

Whenever pus-corpuscles are present in the urine, even in small num- 
bers, an abnormal condition exists somewhere in the genito-urinary tract. 
If they are very scanty, this condition is not necessarily an inflammation, 
though there is undoubtedly an irritation in some portion of the tract. 
As soon as they are found in at least moderate numbers, the diagnosis of 
an inflammation can at once be made, which is the more pronounced the 
greater the number of pus-corpuscles ; when they are very numerous we 
may even be justified in diagnosing suppuration, though not without 
other features. 

Urine containing pus-corpuscles in small numbers may appear per- 
fectly normal to the naked eye, but the greater their number the more 
turbid it becomes, and in urine in which they are abundant a heavy, 
cloudy sediment will sink to the bottom in the course of a few hours. In 
such cases the term pyuria might be properly used. Every urine in 
which pus-corpuscles are present in any appreciable number contains al- 
bumin, no matter from what organ they are derived, and the larger the 
number of pus-corpuscles the greater the amount of albumin. 

Pus-corpuscles, also called leukocytes, are partly emigrated white 
blood-corpuscles, partly derived not only from the connective-tissue cells, 
but also to a great degree from the epithelia themselves, the protoplasm 
of which becomes changed by endogenous new-formation to inflamma- 
tory corpuscles, which later reach the surface of the epithelia and are 



BLOOD-CORPUSCLES AND PUS-CORPUSCLES. 101 

carried along by the urine as pus-corpuscles. They appear mostly as 
small, round, granular bodies, perhaps twice the size of normal red blood- 
corpuscles, in which one or more nuclei may or may not be seen; in 
freshly passed urine they not infrecjuently exhibit active amoeboid 
changes, assuming a variety of irregular forms (see Fig. 47). 

In dilute as well as in highly alkaline urine the pus-corpuscles swell 
and assume a large, globular shape, becoming hydropic. In these a cen- 
tral nucleus will be observed, while the granulations around the periph- 
eral portions become pale or almost entirely disappear. In ammoniacal 
urines, as seen in chronic cystitis, the pus-corpuscles, when present in 
large numbers, burst and coalesce, producing a sticky mass, which can be 



mm 
m 



P ** 



© * @Q 

® ^ip 
f J? % ^ 4 c 

■«B?# *' * 

ft?j8$ ® $ ® ®&® 

Fig. 47. — Pus-corpuscles (X 500). 

F, Pus-corpuscles with fat^globules ; C, ciliated pus-corpuscles ; H, pus-corpuscles with 

haematoidin crystals. 

transferred to the slide only in jelly-like lumps. In such cases a large 
amount of mucus is always present, and it may become almost impossible 
to differentiate the pus-corpuscles from mucus-corpuscles. 

The apparent presence or absence of nuclei in the pus-corpuscles de- 
pends entirely upon the amount of granulation ; in coarsely granular cor- 
puscles they are invisible, but become well marked when the granulation 
is fine. Not infrequently varying numbers of small, glistening fat-glob- 
ules and granules appear in the pus-corpuscles, and this fatty change 
may be so pronounced that almost the entire granulation is altered. 
Such a pronounced change always denotes a chronicity of the inflamma- 
tion, although the fat-globules may commence to appear a few weeks 



102 URINARY ANALYSIS AND DIAGNOSIS. 

after the beginning of the inflammation, when the process cannot as yet 
be called strictly chronic. In perfectly acute inflammations, however, 
they are never found. 

Sometimes pus-corpuscles are seen which contain delicate, rust-brown 
crystals of ha?matoidin, in both needle and plate form. This is more espe- 
cially the case in those derived from epithelia of the pelves of the kidneys 
and the uriniferous tubules of the kidneys, and denotes a previous hem- 
orrhage. In recent hemorrhages the pus-corpuscles may have a uniform 
yellow color, due to the imbibition of the coloring matter of the blood. 
In cases of chronic catarrhal cystitis, dark brown pigment granules may 
sometimes be found in the pus-corpuscles. Occasionally pus-corpuscles 



Eg 



® © © 



Fig. 48. — Pus-corpuscles Showing Different Constitutions (X 500). 
E, Excellent; G, good; M, medium; P, poor. 

which have delicate hairlike prolongations — cilia — are seen. These arise 
from the ciliated columnar epithelia of the uterus, and when present jus- 
tify the diagnosis of an endometritis. Care must be taken not to mistake 
bacteria adhering to the surface of the pus-corpuscles for cilia. 

Constitution. — Pus-corpuscles, when present in moderate or large num- 
bers, will invariably allow us to form an opinion as to the constitution of 
the patient. All pus-corpuscles are granular, the nature of this granula- 
tion varying with the constitution of the individual. This fact was first 
announced in 1879 by Carl Heitzmann, and thousands of examinations 
have proved the correctness of his assertion. It is easy to recognize the 
different appearances of the pus-corpuscles, not only in different cases 
but to a certain degree in the same case, if attention is paid to this fact ; 
some corpuscles appear highly refractive and coarsely granular, while 
others are pale and finely granular (see Fig. 48). 



BLOOD-CORPUSCLES AND PUS- CORPUSCLES. 103 

Coarsely granular, refractive, nearly homogeneous corpuscles, without 
any apparent nucleus, show an excellent, first-class constitution, and the 
more numerous these are in a given case the better the constitution. 
The coarse granulation is due to a large amount of living matter; the 
less living matter present, the finer will be the granulation, and, there- 
fore, the poorer the constitution. In persons having a good constitution, 
the granulation is still coarse, though not to such a great degree as in 
those of an excellent constitution, and the pus-corpuscles will not appear 
as highly refractive as in the latter. When the granulation becomes less 
coarse, a nucleus will be seen in the pus-corpuscle. This is proof of a 
medium constitution, while very finely granular pus-corpuscles, with one 
or more pale nuclei, indicate a poor or broken-down constitution. 

If all the different varieties of granulation, from the coarsely granu- 
lar down to the finely granular, are present, we can come to the conclu- 
sion that the patient had originally a good or even excellent constitution, 
which has become weakened by disease; and the more abundant the 
finely granular, nucleated bodies are, the greater has been that weaken- 
ing. A few months or weeks before the death of an individual if the 
same occurs from a chronic ailment, or even a very short time before 
death if it occurs from an acute affection, the pus-corpuscles break down 
completely and become changed to finely granular, pale, irregular masses. 
These facts can be verified in every case, and will be found of invaluable 
aid in the prognosis. A little study, even with no higher power than 500 
diameters, is sufficient to see easily the differences here noted. 

Attention must, however, be drawn to the fact that it is easy to con- 
found mucus-corpuscles, which are always pale and finely granular and 
are present in every normal urine, with pus-corpuscles. Mucus-corpus- 
cles are normal products of the epithelia, vary considerably in size and 
shape, and are not nucleated; they are, of course, useless in diagnosing 
the constitution, as are hydropic pus-corpuscles. 

Pus-corpuscles may be derived from any portion of the genito-urinary 
tract, and their source can only be determined by the nature of the epi- 
thelia present in the urine. Being invariably found in every inflamma- 
tion, the mildest as well as the most pronounced, they are among the 
most common of all the elements found in the urine. To diagnose an 
inflammation of the kidney, it is by no means necessary to find casts, 
since a number of kidney lesions, sometimes quite severe in character, 
exist without the presence of casts. Irritation from a large number of 
salts, which is common in the pelvis of the kidney, is sufficient to show a 
small number of pus-corpuscles. Although highly alkaline urine fre- 
quently accompanies an inflammation of the bladder, no positive conclu- 
sion can be arrived at without the characteristic epithelia. Again, in the 



104 URINARY ANALYSIS AND DIAGNOSIS. 

urine of a female a large number of pus-corpuscles may be present with- 
out any other trouble than a vaginitis, though this may be sufficient for 
considerable amount of albumin to appear. The same may be said of 
prostatitis and urethritis. Any doubt as to the origin of the pus-corpus- 
cles will at once be dispelled by finding the characteristic epithelia in the 
urine. 



CHAPTER XI. 
EPITHEL1A. 

With very few exceptions, epithelia present in the urine always de- 
note a pathological process of some kind. Normally the only epithelia 
found in urine are irregular, flat epithelia from the bladder, in small 
numbers, while in urine of females there may be flat epithelia from the 
vagina; the presence of all other epithelia is pathological. Although it 
is claimed to be impossible to diagnose the sources of the different epi- 
thelia in the urine, this is not at all difficult, provided a few general points 
are always borne in mind; and it is only by an accurate knowledge of 
their sources that we are able to obtain a diagnosis of the location of the 
morbid process. Most of the morbid processes occurring along the genito- 
urinary tract are inflammatory in nature, and marked by the presence of 
pus-corpuscles in the urine, and the location of the inflammation is deter- 
mined by the epithelia. 

Before speaking of the nature of the different epithelia found in the 
urine, it is necessary to have an idea of the general characters of the 
epithelia occurring in the body. These are of three kinds; First, fat 
or squamous; second, cuboidal; and third, columnar or cylindrical. Flat 
epithelia are always more or less irregular in outline, exhibiting a broad 
front surface, while in edge view they are narrower and somewhat spindle- 
shaped. Cuboidal epithelia have about the same diameter in all direc- 
tions, while columnar epithelia are elongated in one direction. The latter 
may be ciliated, having one or more delicate, hair-like prolongations on 
the outer surface. All epithelia are granular and possess one or more 
nuclei, which, however, need not always be visible and may have dropped 
out, leaving a vacuole. The granulation may be coarse or fine, the flat 
epithelia being frequently more finely granular and paler than the others. 

All epithelia may occur either in a single layer or stratified; that is, 
there may be a number of different layers. Wherever stratified epithelia 
occur and all three varieties are present, the flat variety is seen to com- 
pose the outer or upper layers, the cuboidal the middle layers, and the 
columnar the inner or deepest layer, nearest to the connective tissue. 

In the genito-urinary tract a lining of stratified epithelium is found in 
the pelves of the kidneys, the ureters, bladder, urethra, vagina, and cer- 
vical portion of the uterus, while a simple epithelial lining exists in the 

105 



106 UBINABY ANALYSIS AND DIAGNOSIS. 

uriniferous tubules of the kidneys, the prostate gland, seminal vesicles, 
ejaculatory ducts, Bartholinian gland, and mucosa of the uterus. 

It is maintained that the epithelia from different organs, such as the 
bladder, ureters, and pelves of the kidneys,' are identical in size and shape. 
By scraping off the epithelia of these organs, this idea appears correct ; 
but if the epithelia are examined in situ, we will soon be convinced that 
their sizes vary considerably. The largest epithelia are found in the va- 
gina; the next in size in the bladder; then, in order, those of the cervix 
uteri, urethra, pelves of the kidneys, ureters, and prostate gland; the 
smallest in the uriniferous tubules. It must not be forgotten, however, 
that there are transitional sizes, which are of no value for diagnosis. The 
smallest cuboidal epithelia from the bladder, for instance, may be iden- 
tical with the largest cuboidal epithelia from the pelves of the kidneys, 
but the average size is absolutely different, being considerably smaller in 
the pelves than in the bladder. Again, the caudate and lenticular forms 
of epithelia are far more prevalent in the pelves and calices than in the 
bladder, and are well adapted for a diagnosis. 

All epithelia change to a certain degree in the urine, more especially 
the cuboidal, which are originally angular polyhedral formations; by the 
imbibition of the watery constituent of the urine, they swell and assume 
a more or less regular, even perfectly spherical, form. This change af- 
fects all epithelia alike, and the size of the spheres is sufficient for a diag- 
nosis of their previous location. 

In the vagina and bladder, where the epithelia are large, the differ- 
ence between the flat, cuboidal, and columnar varieties is naturally most 
marked, while in the pelves, ureters, urethra, and cervical portions of 
the uterus it is not so pronounced. In the prostate gland the simple 
epithelial lining is usually cuboidal, though sometimes columnar, while 
in the ducts of the prostate gland and the seminal vesicles it is columnar 
only. In the ejaculatory ducts, as well as in the mucosa of the uterus, 
ciliated columnar epithelia are present, though in the urine the cilia break 
off easily and may not be seen. In the uriniferous tubules of the kidney 
the simple epithelial lining varies in different portions, being partly flat, 
partly cuboidal, and partly columnar; the flat and cuboidal epithelia can- 
not be distinguished, while the columnar variety is well marked. 

In every urine flat, horny epithelia from the genitals — the prepuce in 
the male, and the clitoris and labia in the female — may be found, and are 
called epidermal scales (see Fig. 49). They have a jagged contour, are of 
a rather high refraction, and do not contain a nucleus, but are frequently 
studded with dirt particles and fat globules. In addition, their granula- 
tion — if any is present at all, which is rarely the case — is extremely pale, 
and they appear more or less shrivelled. They vary in size and shape con- 



™ SECOND EDITION 

Atlas of Venereal 
and Skin Diseases. 

With additional new Plates 
and Half=tone Engravings. 

| TEXT ENTIRELY REWRITTEN BY 

JAMES C. JOHNSTON, A. B., M. D. 

WITH THE ADDITION OF CHAPTERS ON ACUTE 
AND CHRONIC GONORHEA BY 

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EPITHELIA. 



107 



siderably, and must not be mistaken for true epithelia or crystals of in- 
complete triple phosphates, which latter they sometimes resemble more 
pronouncedly than the former. 

In attempting to diagnose the sources of the different epithelia, it 
must be remembered that nothing but size will positively differentiate 




Fig. 49. — Epidermal Scales (X 500). 



them, and that a small number of epithelia may be found, the source of 
which cannot be told positively; the larger number, however, are abso- 
lutely characteristic. 

The epithelia found in the urine may be divided into: First, those 
common to both sexes ; second, those found only in the male ; and third, 
those found only in the female. 

Epithelia Common to Both Sexes. — The epithelia found in both 
sexes are those from the bladder, the pelves of the kidneys, the ureters, 
and the uriniferous tubules of the kidneys. The urethral epithelia are 
also the same in both sexes, but are most common in the male. 

Epithelia from the Bladder (see Fig. 50). — The epithelia from the blad- 
der are of three distinct varieties and are easily recognizable; these are 
flat epithelia from the upper layers, cuboidal from the middle layers, and 
columnar from the deepest layer. Flat epithelia may be seen both in 
front view and edgewise, when they may appear more or less folded. A 
small number of these epithelia, without the presence of pus-corpuscles, 



108 



URINARY ANALYSIS AND DIAGNOSIS. 



may be seen in every normal urine. They have no significance whatever, 
since the flat epithelia continually desquamate in health, though in a 
small amount only. As soon as they occur with pus-corpuscles and with 
cuboidal epithelia, they have a pathological significance. These flat epi- 
thelia may be seen either singly or in clusters of varying size. Although 







Fig. 50. — Epithelia from the Bladder (X 500). 
U, Upper layers ; UF, upper layers, folded ; M, middle layers ; D, deepest layer. 



the size of these epithelia is distinctly smaller than that of the epithelia 
from the upper layers of the vagina, a small number may occasionally be 
found, of almost the same size as the latter, derived from the neck of the 
bladder, near the prostate gland. Their number, together with the size 



EPITHELIA. 10!) 

of the cuboidal epithelia and the fact of their not containing bacteria, is 
as a rule sufficient to clear up the diagnosis. 

Cuboidal epithelia from the middle layers are never found in normal 
urine; they may be scant}' or numerous. When cuboidal epithelia are 
present in moderate or large numbers, with many flat epithelia from the 
upper layers, the diagnosis of an acute process can be made. If, on the 
other hand, the upper layers are scanty or entirely absent, the process is 
a chronic one. Whenever fresh exacerbations of an old process set in, 
the flat epithelia become more numerous. 

Columnar epithelia from the deepest layer of the bladder are found 
only in the severer processes, such as intense inflammation, ulceration, 
hemorrhage, and tumors. Care must be taken not to mistake the folded 
upper layers for these more coarsely granular and more highly re- 
fractive epithelia — those from the upper layers being paler and finely 
granular. 

Mention should here be made of an occurrence, which, though it may 
be found in the epithelia of any organ, is most pronounced in the larger 
cuboidal epithelia of the bladder. In different epithelia from the middle 
layers, a number of nuclei or even newly formed, so-called endogenous 
pus-corpuscles will be found. Their number varies from two to four, five, 
or even more. That pus-corpuscles are formed within epithelia can be 
easily observed. A few of these new-formations can often be seen in dif- 
ferent inflammations, but larger numbers will be found in the epithelia 
only after a long-continued irritation through some pressure, usually 
from the outside. Such endogenous new-formations are seen in cases of 
hypertrophied prostate gland, undoubtedly caused by pressure of that 
organ upon the bladder, as well as in different exudations behind the 
bladder, such as a parametritic exudate or a tumor in the wall or vicinity 
of the bladder. 

All cuboidal and columnar epithelia may contain a varying number 
of secondarily developed, glistening fat-granules and -globules similar to 
those seen in the pus-corpuscles. This is invariably an indication that 
the process has lasted for some time and is not an acute one. A large 
number of these globules always indicates a chronic process. 

Epithelia from Pelvis of Kidney (see Fig. 51). — In the pelves of the 
kidneys the epithelia also vary considerably in shape, being partly globu- 
lar, but mostly irregular. They are smaller than those from the bladder, 
but larger than those from the ureters, the epithelia from which latter 
are almost always present with those from the pelves. The majority of 
the pelvic epithelia are caudate, pear-shaped, or lenticular, though they 
are sometimes quite irregular; the regular, cuboidal shapes, smaller than 
those from the bladder, being less numerous. The epithelia are frequently 



no 



URINARY ANALYSIS AND DIAGNOSIS. 



seen with uric-acid gravel, which causes an irritation or inflammation of 
the pelvis. 

Epithelia from the Ureters. — Epithelia from the ureters are rarely 
found alone, but usually with those from the pelvis. Their characteristic 
shape in the urine in most cases is round, globular, or slightly irregular, 




Fig. 51. — Epithelia from Pelvis of Kidney and Ureter (X 500). 
P, Pelvis of kidney; U, ureter. 



being distinctly smaller than those from the pelvis. They cannot be dif- 
ferentiated from the epithelia of the prostate gland, which they closely 
resemble. Their number in the urine is, as a rule, small; and the fact of 
their being associated with epithelia from the kidney and pelvis of kidney 
makes their diagnosis easy. Occasionally small columnar epithelia from 
the deepest layer are seen. These are caudate or pear-shaped and are 
found in deep-seated processes, such as ulcerations due to impacted cal- 
culi or tubercular lesions. In traumatism, which may be due to ureteral 
catheterization, they are not rarely present in the urine. 

Epithelia from the Uriniferous Tubules of Kidneys (see Fig. 52). — 
Epithelia from the uriniferous tubules are the most important of all the 
epithelia found in the urine and those most frequently overlooked. When- 
ever they are present in the urine, with pus-corpuscles, even when no 
casts whatever can be found, the diagnosis of a pathological process in 
the kidney is certain, since they are never seen normally in urine. Two 
distinct forms are found: the cuboidal from the convoluted tubules, and 



EPITHELIA. 



Ill 



the columnar from the straight collecting tubules. These epithelia are 
distinctly smaller than either those from the pelvis of the kidney or the 
ureter in the same case, though their sizes vary to a certain degree in dif- 
ferent cases. They are round, globular, or slightly irregular. 

In every case examined the first step is to look for pus-corpuscles, 
which are known to be small in some individuals and comparatively large 
in others, and are usually the smallest granular corpuscles seen. They 
may vary in size in the same case, but to a slight degree only. As soon 
as these are decided upon, the next step is to determine whether bodies 
distinctly larger than these are present. If such bodies, about one-third 
larger than pus-corpuscles, are found in at least moderate numbers, we 
can be certain that they are epithelia from the convoluted and narrow 
tubules of the kidney. The presence or absence of a nucleus has no sig- 
nificance whatever, although such a nucleus is usually found in the kidney 
epithelia, but may be invisible in the pus-corpuscles. The relation be- 
tween the size of the pus-corpuscles and that of the epithelia from the 
convoluted tubules is always the same; that is, the latter are about one- 




Fig. 52. — Epithelia from Uriniferous Tubuees of- Kidneys (X 500). 
C, Convoluted tubules ; S, straight collecting tubules. 



third larger in diameter than the former. If the pus-corpuscles happen 
to be small in the case examined, the kidney epithelia will be small; but 
if large, the epithelia will be large. 

The comparative sizes of the different smaller formations found in the 
urine are illustrated in Fig. 53. The smallest corpuscles with double con- 



112 URINARY ANALYSIS AND DIAGNOSIS. 

tour ; and which are not granular, are the red blood-corpuscles; the next 
in size, being the smallest granular corpuscles, are the pus-corpuscles; 
then follow the smallest epithelia found in urine, one- third larger than 
the pus-corpuscles — the epithelia from the convoluted tubules of the kid- 
ney. Finally, the next larger epithelia are shown, always about twice the 



■ ■■-Oh f- z i- -; 



Fig. 53. — Comparative Sizes of Corpuscles and Epithelia (X 500). 

diameter of the pus-corpuscles, which are either those from the ureters or 
the prostate gland, between which no difference can be noticed. If this 
relationship is kept in mind, no mistake can be made, though it must be 
remembered that when an individual small formation is found, the diag- 
nosis cannot be made positively until compared with the pus-corpuscles. 

Besides the cuboidal epithelia, columnar epithelia from the straight 
collecting tubules are sometimes found. The latter are, as a rule, not as 
abundant as the former, and are almost invariably seen in larger numbers 
in the severer cases of nephritis only. Their size, as compared with that 
of the cuboidal epithelia, is about the same, they being narrower, but 
elongated. In very acute cases of nephritis clusters of kidney epithelia, 
as well as cast-like tubes of epithelia, though not necessarily true casts, 
may be found. 

Although it is the usual custom to rely entirely upon the presence of 
casts in the urine before making the diagnosis of a nephritis, it will be 
found that casts are frequently absent, even in pronounced cases of kid- 
ney inflammations, as, for instance, in catarrhal or interstitial nephritis; 
and that even in cirrhosis of the kidney, casts are, as a rule, entirely ab- 
sent, or, if present, are extremely scanty. If care is taken to look for 
epithelia about one-third larger than pus-corpuscles, the diagnosis of a 
nephritis can be made in many cases which are otherwise overlooked, 
even though a small or even moderate amount of albumin be present in 
the urine. Too much stress cannot be laid upon this fact, as, in many 
cases where the clinical symptoms undoubtedly point to a nephritis, the 
diagnosis is abandoned because no casts are found. This variety of 
nephritis is much more common than is usually supposed, though in 
most cases of a milder character than the parenchymatous variety, and 
it may often last for a number of years without being detected. 

The diagnosis of epithelia from the upper urinary tract has of late 



EPITEELIA. 



113 



years been simplified by ureteral catheterization. Whenever such urines, 
obtained by means of the ureteral catheter, are examined, where the 
presence of epithelia from the bladder or the genital tract can positively 
be excluded, only those epithelia which have been described as being de- 
rived from the ureter, pelvis of kidney, and uriniferous tubules are found. 

Epithelia Found in Urine of Male. — The epithelia found in the urine 
of the male are those from the urethra, the prostate gland and its duct, 
the seminal vesicles, and the ejaculatory duct. 

Epithelia from Urethra (see Fig. 54). — The epithelia from the urethra 
vary considerably in size and shape, being partly flat, partly cuboidal, 
and partly columnar, and in most cases are comparatively large and ir- 
regular, so that they can be easily diagnosed. The larger irregular, partly 
flat, partly cuboidal epithelia are seen in milder inflammations, such as 
the first stages of catarrhal or gonorrhceal inflammations; the irregular 
columnar or cylindrical epithelia occur only in deeply seated inflamma- 
tions or ulcerations, which often lead to the formation of a stricture. 

Epithelia from Prostate Gland (see Fig. 55). — The epithelia from the 
prostate gland are partly cuboidal and partly columnar, the latter orig- 




Fig. 54. — Epithelia from Urethra (X 500). 



inating both in the alveoli and the excretory ducts of the gland. The 
cuboidal epithelia are of exactly the same size as the cuboidal epithelia 
from the ureters, being about twice as large as the pus-corpuscles in every 
case, and distinctly larger than those from the convoluted tubules of the 
8 



114 



URINARY ANALYSIS AND DIAGNOSIS. 



kidney. When epithelia of this size are seen in a given case, care must 
be observed to take the relative numbers of these, as well as of those from 
the convoluted tubules and the pelvis of the kidney, into consideration 
before reaching a positive diagnosis. For instance, if they are present in 
large numbers, while those from the kidneys and pelves are entirely ab- 




Fig. 55. — Epithelia from Prostate Gland, Seminal Vesicles, and Ejaculatory 

Ducts (X 500). 
P, Prostate gland and its ducts; E, ejaculatory ducts; S, seminal vesicles. 



sent or seen in small numbers only, they are undoubtedly prostatic. The 
clinical history, if known, will, of course, clear up this point still further. 

The columnar epithelia, partly from the ducts of the gland, w r hich are 
distinctly larger than those from the straight collecting tubules of the 
kidney, are rarely absent in pathological processes of the prostate gland, 
and will render the diagnosis plain, since columnar epithelia from the 
ureters, which they resemble, are not frequently seen, and, when present, 
are usually found in small numbers only. The latter also are more cau- 
date than the former. 

In many cases of posterior urethritis associated with prostatitis, 
groups of round, oval, or slightly irregular epithelia are found. These 
are larger than the prostatic epithelia just described, resembling in size 
the cuboidal epithelia from the pelvis of the kidney, but are pale, usually 
finely granular, with their nuclei frequently indistinct. They are hy- 
dropic, and may be derived from both the prostate gland and the pros- 
tatic portion of the urethra. 

Mention should be made here of the fact that in rarer cases pale, con- 



EPITHELIA. 



Hi 



centric formations of varying sizes are found with the prostatic epithelia. 
These are the so-called prostatic concretions, colloid or amyloid corpus- 
cles of the prostate gland (see Fig. 56). They are irregular, partly oval, 
partly angular bodies, which have a high refraction and a more or less 
pronounced concentric striation, frequently with an irregular central nu- 
cleus. Their number seems to be augmented in some cases of hyper- 
trophy of the gland. 

Epithelia from Seminal Vesicles. — Epithelia from the seminal vesicles 
(see Fig. 55) are frequently associated with those from the prostate gland. 
Their presence in urine with pus-corpuscles indicates an inflammation or 
suppuration in the vesicles. These epithelia are always columnar and 
non-ciliated. They are more or less irregular, either of the same size or 
slightly larger than the columnar epithelia from the prostate, and in the 
organ contain yellow pigment. The pigment is sometimes, but not al- 
ways, seen in the epithelia in urine. 

Epithelia from Ejaculatory Ducts. — Epithelia from the ejaculatory 
ducts may also be found in the urine. They are of the columnar ciliated 




Fig. 56. — Sperma as Found in Urine (X 500). 



variety, and perfectly characteristic. The cilia are not always seen, since 
they break off easily and become lost; but delicate parallel rods in the 
interior of the epithelia, near their basal surface, may then indicate that 
the epithelia were originally ciliated. When no cilia or rods are found, 
their size alone will usually be sufficient for a diagnosis, as they are 
smaller and considerably narrower than those from the bladder. 



116 URINARY ANALYSIS AND DIAGNOSIS. 

Sperma. — Not infrequently sperma, the characteristic ingredients of 
which are the spermatozoa, is found in urine, normally as well as patho- 
logically. This will be the case after sexual intercourse, as well as after 
emissions, and in spermatorrhoea, which latter can best be diagnosed 
from the almost constant presence of sperma in urine, especially the first 
urine voided in the morning. When sperma is found in small amount 
only, the appearance of the urine is not changed; but when present in 
large amount, cloudy, flaky deposits are seen, which, when examined, 
prove to be sperma. 

In urine the positive diagnosis of sperma can only be made when 
spermatozoa are found, though prostatic epithelia, and occasionally sper- 
matic concretions, may be present (see Fig. 56). The other ingredients 
of sperma, such as the sperma crystals, are rarely seen in urine. 

Spermatozoa, which are about 5^0 ° r -^ of an inch long, consist of a 
flattened, oval, or pear-shaped head, a small cylindrical middle portion 
or neck, which, however, is not always seen, and a long, wavy, tapering 
tail, considerably broader at the head than at the end. In perfectly fresh 
urine a slight motion of the spermatozoa may be visible for a short time, 
but disappears very soon. They are extremely resistant toward chem- 
ical reagents, and may be found well preserved in urine after days, even 
when it is strongly alkaline. 

The number of spermatozoa in urine varies greatly. Under normal 
conditions the spermatozoa are rarely abundant, while in cases of sperma- 
torrhoea they are usually quite numerous and may be present in very 
large numbers. In cases of spermatocystitis or seminal vesiculitis they 
are frequently seen, and many of them will be found changed, the head 
gradually enlarging, becoming more round and often granular. It is not 
unusual for the head to assume the size of a pus-corpuscle, which it may 
resemble to such a degree that it is impossible to differentiate it from the 
latter; in appearance, it is like a pus-corpuscle with a tail. In these cases 
pus-corpuscles, epithelia from the prostate gland, from the seminal ves- 
icles, and frequently also from the ejaculatory ducts will be present. 

Urethral and Gleet-Threads. — Although no distinction should be made 
between urethral and gleet-threads or filaments (the latter originating in 
the urethra), there are cases in which men who have never suffered from 
gonorrhoea mil void small, transparent mucus-threads or filaments with 
the first morning urine. These are always scanty, and consist of nothing 
but mucus, both threads and corpuscles, together with the larger, flat, 
superficial urethral epithelia. These masses are conglomerations of mu- 
cus in the urethra, and are not pathological. 

On the other hand, we find in the urine of persons who have suffered 
from gonorrhoea, at one time or another, either only a short time pre- 



EPITHELIA. 117 

viously or many years before, a varying number of filaments, which dif- 
fer in size and may appear either perfectly transparent or more or less 
opaque. These are the regular gleet-threads (see Fig. 57). 

It is not uncommon to find such filaments accidentally in the urine of 
persons who, though they suffered from gonorrhoea a long time previ- 
ously, have not noticed any symptoms for years. In these cases they 
are, of course, small and scanty. More frequently are they found in 
those cases of chronic gonorrhoea in which slight symptoms, such as a 
moisture at the orifice of the urethra or an adhesion of the lips of the 




Fig. 57. — Gleet-Threads (X 500). 

PC, Pus-corpuscles; M, mucus-fibres; PE, epithelium from the prostate gland; DE, 

epithelium from the ducts of the prostate gland ; UE, epithelium from the urethra. 

meatus in the morning, with subsequent discharge of a minute drop of 
either mucous or muco-purulent fluid, are present. The number of fila- 
ments in cases of this kind is at times very large. Fortunately, gonococci 
are not found in all these cases, but may be entirely absent in the larger 
number, and repeated careful examinations will fail to find them. 

Regular gleet-threads consist of mucus, pus-corpuscles (the latter usu- 
ally abundant in the more pronounced cases), and a varying number of 
epithelia from the urethra and the prostate gland; sometimes, also, from 
the neck of the bladder. The larger number of pus-corpuscles, as well as 
most of the epithelia, will be found studded with fat-globules and -gran- 



118 



URINARY ANALYSIS AND DIAGNOSIS. 



ules, which latter are not infrequently seen in smaller or larger groups 
upon and between the mucus, outside of the pus-corpuscles and epithelia. 
The more chronic the case, the more numerous are the fat-globules. The 
appearance of such so-called gleet-threads under the microscope is always 




Fig. 58. — Epithelia from the Vagina (X 500). 
U, Upper layers ; UF, upper layers folded ; M , middle layers ; D, deepest layer. 



perfectly characteristic, though the name is misleading, since, when they 
are large, a number of fields can be found crowded with pus-corpuscles, 
mucus, and epithelia not in the least resembling a thread. 

The more severe the case, the more abundant are the pus-corpuscles, 



EPITHELIA. Ill) 

and care is necessary in such cases not to make an error in the diagnosis, 
which would be easy when the presence of gleet-threads is not suspected. 
A wrong diagnosis of an abscess might thus be made, although such a 
diagnosis is never justified without the presence of a number of connective- 
tissue shreds, which are never seen here. In the milder forms the mucus 
is abundant, and the pus-corpuscles mixed with it often change and as- 
sume various irregular shapes, the spindle shape being frequent. It is 
impossible to judge of the chronicity of a case from these,* as has been 
claimed. Again, the pus-corpuscles may swell and become hydropic, or 
the cover glass may have been accidentally pressed in mounting the speci- 
men, either of which is sufficient to change the appearance of the pus- 
corpuscles. Spermatozoa may at times be found mixed with the gleet- 
threads, but will, of course, not affect the diagnosis in any form. 

Epithelia Found in Urine of Female. — The epithelia found in the 
urine of the female are those from the vagina, the Bartholinian gland, 
the cervix of the uterus, and the mucosa of the uterus. 

Epithelia from Vagina. — The epithelia from the vagina are the largest 
found in the urine; those from the upper layers are flat, those from the 
middle layers are cuboidal, and those from the deepest layer are colum- 
nar (see Fig. 58). 

The flat epithelia are present in varying numbers in most female 
urines, and when found alone have no significance, since they continually 
desquamate in health. When leucorrhoea is present, as is almost always 
the case, in a small degree, in healthy women who have borne children, 
their number is considerably augmented. They may be found singly or 
in variously sized clusters, and are always large, irregular, and usually 
studded with bacteria — both cocci and bacilli. They frequently contain 
large fat-globules, which, of course, have here no significance; they are 
often seen folded or edgewise, when they are narrow but irregular, and 
cannot be mistaken for columnar epithelia. Their granulation is fine, and 
the epithelia, therefore, pale. 

The cuboidal epithelia from the middle layers are abundant in inflam- 
mations of the vagina. They are considerably larger than those from the 
bladder, have one or more nuclei, and in chronic inflammations contain 
fat-granules and -globules. These are also found in clusters of consider- 
able size. 

The columnar epithelia from the deepest layer, much larger than 
those from the bladder, are seen only in intense, deep-seated inflamma- 
tions or ulcerations, where they may sometimes be found in large num- 
bers. 

Smegma. — Of common occurrence in the urine of the female are clus- 
ters of epidermal scales, so-called smegma, partly from the clitoris, partly 



120 



URINARY ANALYSIS AND DIAGNOSIS. 



from the labia, or from the vagina. Smegma may also be found in small 
amount in the male, from the prepuce, but here it is not so common nor 
seen in such enormous masses as in the female (see Fig. 59) . 

Smegma consists of closely packed masses of variously sized epidermal 
scales filled to a greater or less degree with bacteria — both cocci and ba- 




Fig. 59. — Smegma from the Clitoris (X 450). 



cilli — and also with extraneous fat-globules, as well as particles of dirt. 
The individual scales, as before said, are never nucleated and rarely 
granular, but appear shrunken. Such masses, which have been seen tec 
cover an entire field of the microscope, are highly refractive, and when 
large can be seen with the naked eye. 

Epithelia from Bartholinian Gland (see. Fig. 60). — The epithelia from 
the Bartholinian gland resemble in size the round or slightly irregular 
epithelia from the prostate gland in the male, being about twice the di- 
ameter of pus-corpuscles. They are frequently present when the vaginal: 
epithelia are found in moderate or large quantities. 

Epithelia from Cervix Uteri. — Epithelia from the cervical portion ofr 
the uterus are partly flat, partly cuboidal, and partly columnar, and quite 
large, though considerably smaller than those from the vagina, and al- 
ways more irregular. These epithelia may be characteristic, but thej 
sometimes so resemble the irregular epithelia from the urethra as to be 



8 



A Guide to the 

Clinical 
Examination 
of the Blood 

For Diagnostic 
Purposes. 

By RICHARD C. CABOT, M. D. 



FIFTH REVISED EDITION. 



i 



The fifth revision of this standard work 
has been most thorough, the text having 
been almost entirely rewritten. 

A special feature of the book is the colored 
illustrations, with which great pains have 
been taken, and they will be found more 
useful than pages of description, especially 
as they represent actual microscopic fields, 
and are not all "diagrammatic." Octavo, 
569 pages, illustrated by numerous wood- 
engravings, and by 17 chromo-lithographic 
and black plates. Muslin, $3.50, net, brown 
leather, $4.50, net. 



PRESS NOTICES 

" For those who are familiar with this work it 
needs no commendation. For those who are not 
familiar no commendation can do it justice." 

The Cliniqtje. 
" It is indispensable both to the student and to the 
practitioner." 

Boston Med. and Stjrg. Jour. 



Sent, postpaid, on receipt of price. 



Wm. Wood & Co. 



51 FIFTH AVENUE, 



NEW YORK, 



\mSBSSBSSm 







EPITHELIA. 



121 



difficult of differentiation. The latter are found in the female as well as 
the male, though generally in smaller numbers. 

Epithelia from Mucosa Uteri. — Epithelia from the mucosa of the 
uterus, indicating a catarrhal endometritis, are also not rare in the urine. 
They are delicate, columnar, ciliated formations, smaller than those de- 
scribed as being derived from the ejaculatory ducts. The cilia on the 
surface of these epithelia are frequently well marked, and as many as 
three or four may be found; occasionally, however, they are broken off. 
With them we may see ciliated pus-corpuscles, which arise from the epi- 
thelia, and cannot come from any other locality than the uterus. In 
freshly voided urine the cilia from both these formations may be seen in 
waving motion. 

If the epithelia just described are carefully studied, we will soon be- 
come convinced that the formations from the different organs of the 
genito-urinary tract can undoubtedly be differentiated, and that diag- 
noses of the different lesions can be made with great certainty. In every 




Fig. 60. — Epithelia from Bartholintan Gland, Cervix Uteri, and Mucosa Uteri 

(X 500). 
BE, Bartholinian gland ; CE, cervix uteri ; UE, mucosa uteri. 

case in which at least a moderate number of epithelia is found in the 
urine, most of these are characteristic of the organ from which they are 
derived. There will, of course, always be a few whose origin must remain 
doubtful, but these are not sufficiently numerous to cause errors. The 
more cases we examine, the more convinced we will become of this fact. 



122 TJRINABY ANALYSIS AND DIAGNOSIS. 

The clinical history of the case will bear out the microscopical diagnosis 
every time, and frequently the microscope gives the first indication of 
some pathological condition which has as yet escaped detection, but 
which sooner or later is bound to give clinical symptoms. In no organ is 
this more pronounced than in the kidney, where mild cases of nephritis, 
which unfortunately escape detection for months or years, may be pres- 
ent, until suddenly the pronounced symptoms of a chronic nephritis or a 
cirrhosis of the kidney develop. Conscientious examination of the urine 
for kidney epithelia and pus corpuscles will often repay the physician in 
cases where, although he has found a trace of albumin, he will banish 
from his mind all idea of an inflammation of the kidneys because no casts 
are present. 



CHAPTER XII. 

MUCUS AND CONNECTIVE TISSUE. 
I. MUCUS. 

Mucus is found in small amount in every normal urine, being, as a 
rule, more abundant in females. It appears in the form of threads and 
corpuscles, and is a normal physiological product of the epithelia (see 
Fig. 61). 

Mucus-threads are finely striated, pale, often scarcely perceptible 
strings of different sizes. In normal urine they are always small; but in 
inflammations, especially those of the genital tract, may assume large 
proportions. The strings are made up of pale, more or less parallel fibres, 
and when large may branch in different directions. 

Besides threads, mucus-corpuscles are of frequent occurrence. These 
corpuscles vary in size from that of a pus-corpuscle to that of larger epi- 
thelia; are pale, more or less irregular in outline, always finely granular, 
and non-nucleated. They are easily distinguished from pus-corpuscles by 
their greatly varying sizes, pale appearance, and absence of a nucleus, 
which latter is seen in finely granular pus-corpuscles. 

Mucus-threads not infrequently appear in the form of delicate, stri- 
ated formations, resembling casts, the so-called cylindroids or mucus- 
casts (see Fig. 62). Although at times greatly resembling hyaline casts 
in their outline, they can usually be distinguished from them by their ir- 
regular contours, their tapering ends, and their more or less striated in- 
terior, since they are nothing but conglomerations of mucus-fibres. They 
may be quite long and are often twisted and folded. They may be found 
whenever mucus is present in larger amounts, and may be derived from 
any portion of the genito-urinary tract. They undoubtedly have no 
further significance than mucus in general. 

Mucus is greatly augmented in all inflammatory conditions, but more 
especially in inflammations of the bladder and the genital organs, such as 
the urethra, prostate gland, and vagina. In the latter, mucus-threads 
are often large, cylindrical, and twisted, and may be perceptible to the 
naked eye. The so-called gleet-threads are nothing but conglomerations 
of mucus, in which large numbers of pus-corpuscles and epithelia are em- 

123 



124 



URINARY ANALYSIS AND DIAGNOSIS. 



bedded. Irritation of the urinary tract, due to highly acid urine, con- 
taining uric acid and sodium urate, increases the amount of mucus, and, 
the urates being precipitated upon it, the stringy masses become more 
easily perceptible. Fat-granules and -globules, so frequently found in the 
urine, may also conglomerate upon mucus-threads and so-called cylin- 
droids. 

In chronic inflammations of the bladder the urine appears ropy, on 




Fig. 61. — Mucus-Threads and -Corpuscles (X 500). 



account of the abundance of mucus. Simple irritation of the sexual or- 
gans is sufficient to increase the amount of mucus, and if sperma is mixed 
with the urine its mucous constituents appear as pale, flaky masses en- 
tangled with spermatozoa. 

Finally, an increased amount of mucus may be seen in the urine in 



MUCUS AND CONNECTIVE TI88UE. 



L25 



different febrile conditions, without any inflammation in the urinary 
tract; and in acute contagious diseases, such as scarlet fever, it fre- 
quently appears as a precursor of a nephritis. 




Fig. 62. — Mucus-Casts or Cylindroids (X 500). 



II. CONNECTIVE TISSUE. 



As all the organs containing epithelia also contain connective tissue, 
it is evident that this formation can frequently be found in the urine, 
though only in the more intense, deeper-seated pathological processes. 
Its occurrence has, however, been entirely overlooked, except in the rare 
cases in which particles of tumors, especially from cancers, have been found 
in the urine. That connective-tissue shreds are of comparatively common 



126 



VJRIXABT ANALYSIS AND DIAGNOSIS. 



occurrence was first pointed out by Carl Heitzmann. who described then- 
appearance under a number of different conditions. The reason for their 
being overlooked seems to be, partly, that in many cases they are small, 
though easily seen, and partly that they have been mistaken for mucus- 
strings or extraneous substances, such as linen and cotton fibres. 




Fig. 63. — Coxxective -tissue Shreds ( X 500). 



Connective-tissue shreds (see Fig. 63) vary in size, and are made up 
of wavy, moderately refractive fibres, the individual fibres being rarely 
single, but conglomerated in the form of small, irregular bundles, which 
again form larger bundles. These bundles, then, are always fibrillary and 
frequently finely granular, sometimes even containing formations resem- 
bling nuclei — the connective-tissue corpuscles. They may be so small 
and delicate as entirely to escape detection with a magnifying power of 



MUCUS AND CONNECTIVE TISSUE. 127 

less than 500 diameters, or so large as to cover half or even the entire 
length of a field, and of varying thickness. They are easily differentiated 
from mucus-threads by their moderate refraction and their wavy, irregu- 
lar fibres, in contradistinction to the pale appearance and more or less 
regular fibres of mucus, which frequently run in a parallel direction for a 
considerable distance. On the other hand, linen fibres, or, rather, the 
smaller fibrillar of linen, with which they might also be confounded, are 
of a still higher refraction, and are coarser, the individual fibrillar being 
split up in an entirely different manner, and are never as wavy as the 
connective-tissue shreds. 

The pathological conditions under which connective- tissue shreds are 
found may be divided into the following: 

1. Ulceration. 

2. Suppuration. 

3. Hemorrhage. 

4. Traumatism. 

5. Tumors. 

6. Hypertrophy of the prostate gland, with inflammation of 

that organ. 

7. Stricture of the urethra. 

8. Cirrhosis of the kidney. 

9. Atrophy of the kidney. 

10. In all other intense inflammatory processes, but in small 
amount only. 
As an example of the latter, the croupous or parenchymatous inflam- 
mation of the kidney may be mentioned, in which, if it is at all severe, 
connective-tissue shreds will be found in small numbers. 

1. Ulceration. — Ulcerative processes are quite common occurrences, 
and may be found in any part of the genito-urinary tract, but more espe- 
cially in the bladder, pelvis of kidney, urethra, and vagina. In such 
ulcers the connective-tissue shreds are usually broad and numerous, pus- 
corpuscles are present in moderate or fairly large numbers, and the loca- 
tion of the ulcer can always be determined by the presence of the charac- 
teristic epithelia ; these are abundant, and found not only from the more 
superficial, but also from the deeper layers. Besides these formations, 
the freshly voided urine contains variously sized conglomerations of 
cocci, in the form of zooglora masses, especially around the connective- 
tissue shreds, as well as small numbers of other bacteria. 

2. Suppuration. — The presence of an abscess in any organ can be 
diagnosed when connective-tissue shreds in large numbers are seen with 
numerous pus-corpuscles and epithelia from the organ in which the ab- 
scess is situated, this being most frequently either the kidney, the pelvis 



128 UBINAEY ANALYSIS AND DIAGNOSIS. 

of the kidney, the prostate gland, or the seminal vesicles. In many cases 
we will also see pronounced endogenous new-formations in the epithelia 
of the neighboring organs, as the result of pressure upon that organ. 
An abscess of the prostate gland, for instance, may give endogenous new- 
formations in the epithelia of the bladder, as ,well as of the urethra. 
Large numbers of pus-corpuscles and epithelia alone, without the pres- 
ence of connective-tissue shreds, are never sufficient to diagnose an ab- 
scess. As soon, however, as these shreds, showing a destructive process, 
are found, the diagnosis becomes plain. The connective-tissue shreds, 
although always quite numerous, may vary considerably in size. 

3. Hemorrhage. — In hemorrhages of the genito-urinary tract, it is 
often quite difficult to find the epithelia showing their source — the more 
abundant the hemorrhage, the greater the difficulty. It sometimes re- 
quires hours to arrive at a definite conclusion, though a certain number 
of epithelia will always be found sooner or later. In all such cases con- 
nective-tissue shreds are present, but are occasionally quite scanty and 
small, except when the hemorrhage is due to a tumor. They have, as a 
rule, a yellowish tint, from the coloring matter of the blood. In hemor- 
rhages red blood-corpuscles are very abundant, and white blood-corpus- 
cles are generally seen in small numbers. Strings of fibrin, which must 
not be mistaken for connective tissue, are found in many of these cases, 
but pus-corpuscles are absent as long as there is no inflammation; if a 
hemorrhage intervenes upon an inflammation, all the evidences of the 
latter will, of course, be present with the former. 

4. Traumatism. — Since traumatism, due to various causes, is frequently 
accompanied by hemorrhages or even ulcerations, the features would be 
those above given. There are, however, cases in which the injury does 
not cause a pronounced hemorrhage, yet the destructive process to the 
tissue is sufficient for connective- tissue shreds to appear in the urine, 
with but a few red blood-corpuscles. Among these may be mentioned 
slight injuries, due to the passage of a small amount of gravel; injury to 
the ureter, due to the passage of the ureteral catheter, which may be 
quite extensive; mechanical injury of the orifice of the vagina, due to 
masturbation; or injuries of the cervix uteri. In mechanical injuries, 
such as are caused by masturbation, vaginal epithelia from all three 
layers are found, together with a large number of epidermal scales from 
the labia, usually containing fat-globules, epithelia from the Bartholinian 
gland, a few pus-corpuscles, possibly a few red blood-corpuscles, and a 
small or moderate number of connective-tissue shreds. When the num- 
ber of vaginal epithelia is not large, and connective-tissue shreds appear 
with numerous irregular epithelia from the cervix, with only a few pus- 
corpuscles, injuries around the cervix are indicated. Although of com- 



MUCUS AND CONNECTIVE TISSUE. 129 

paratively small practical importance, it must be known that connective- 
tissue shreds in the urine of females may be due to such causes. 

5. Tumors. — In all tumors which can be diagnosed from the urine, 
such as papilloma, sarcoma, and cancer, connective-tissue shreds are the 
most important diagnostic features, without which the presence of a tu- 




Fig. 64. — Connective-tissue Shreds Found in Tumors (X 500). 

mor cannot be positively diagnosed. Besides these, other evidences of a 
tumor are frequently found, though the connective-tissue shreds them- 
selves may be characteristic enough for a diagnosis. 

In papilloma such shreds are always large, very irregular, frequently 
branched, and often assume the shape of coils or knobs (see Fig. 64). 
9 



130 URINARY ANALYSIS AND DIAGNOSIS. 

They are coarsely granular and may contain a number of inflammatory 
corpuscles. In rare cases blood-vessels in process of formation or fully 
developed may also be found in them. Besides these large masses, the 
regular connective-tissue shreds are also present in varying amount. A 
number of irregular, coarsely granular epithelia, the covering epithelia of 
the papilloma, will usually be seen in such cases, though they are not 
found in situ and are not of much value for a diagnosis. 

In cancer of the bladder, especially villous or papillary, the connec- 
tive-tissue shreds are occasionally still larger and more irregular, forming 
so-called cauliflower-like excrescences. They are infiltrated with inflam- 
matory corpuscles, sometimes to a great degree, and often contain large 
cancer epithelia or even epithelial nests. Besides these shreds, such 
cases contain a varying number of epithelia about the size of those from 
the middle layers of the bladder, but extremely irregular, coarsely granu- 
lar, and having numerous nuclei or pus-corpuscles in their interior — the 
so-called endogenous new-formations. In rarer cases variously sized can- 
cer nests are also present. As a rule, both the connective-tissue shreds 
and the epithelia are seen crowded with fat-globules and -granules. The 
epithelia alone are never sufficient for a diagnosis, but as soon as the! 
shreds just described are present the case becomes plain. That pus-cor- 
puscles, bladder epithelia, and usually red blood-corpuscles are always 
found in these tumors is evident. 

In sarcoma, which can develop in any organ of the genito-urinary tract 
and the location of which can be diagnosed according to the epithelia 
present, the connective-tissue shreds are frequently of very large size, but 
not characteristic. Here peculiar, glistening, coarsely granular, almost 
homogeneous corpuscles, smaller than pus-corpuscles but larger than red! 
blood-corpuscles, are found in large numbers and variously sized groups. 

6. Hypertrophy of Prostate Gland. — An enlargement of the prostate 
gland, when slight and unaccompanied by an inflammation, does not 
give connective-tissue shreds in the urine. As soon, however, as the 
hypertrophy becomes more pronounced and is accompanied by an in- 
flammation, connective-tissue shreds, which may be small and scanty, 
appear in the urine, with pus-corpuscles and epithelia from the prostate 
gland and duct. Besides these features, we usually find the endogenous 
new-formations in the epithelia of the bladder or urethra, or both. 

7. Stricture of Urethra. — A diagnosis of stricture of the urethra can! 
also be made in a number of cases from an examination of the urine. 
This is of little practical value. In these cases cuboidal and columnar 
epithelia from the urethra, many of which have pronounced endogenous 
new-formations, are found with pus-corpuscles, red blood-corpuscles, and 
connective-tissue shreds in varying numbers. The features of an existing 



MUCUS AND CONNECTIVE TISSUE. 1.51 

hypertrophy of the prostate or a stricture of the urethra are not neces- 
sarily found in every specimen of urine. 

8, 9. Cirrhosis and Atrophy of Kidney. — Every chronic interstitial 
nephritis sooner or later leads to cirrhosis of the kidney, and every chronic 
parenchymatous nephritis to atrophy of the kidney. In both of these af- 
fections connective-tissue shreds are also present, usually in small amount 
only in cirrhosis, but always in larger amount in atrophy. The features 
found in the urine in these diseases, besides connective-tissue shreds, are 
numerous and so constant that a diagnosis is simple. 

10. That connective-tissue shreds may be also found in small num- 
bers in every intense inflammation, is evident from what has been said. 
In tuberculosis of any organ of the geni to-urinary tract, for instance, 
even if as yet unaccompanied by ulceration, a few T shreds may be present 
in the urine. As soon as connective-tissue shreds, however small, are 
found, it becomes evident that the pathological process cannot be a mild 
one. 



CHAPTER XIII. 

TUBULAR CASTS. 

Tubular casts were first carefully described as occurring in the tu- 
bules of the kidney and found in the urine by Henle in the year 1842, al 
though they were probably seen a few years before that time by different 
observers. Many years later, in 1867, Rovida gave a thorough account 
of their nature and formation. Henle considered them to be coagulated 
fibrin, but the views concerning their origin have become greatly changed 
since that time. They were at one time considered to be products of 
secretion of the epithelia of the tubules, at another time to be transformed 
or disintegrated epithelia. Later on, the blood-vessels were supposed to 
be principally concerned in their production, at least in that of the hya 
line casts, without any participation of the epithelia. 

One of the older views was that casts are produced by the coagula- 
tion of an albuminous substance, the supposition being based upon the 
fact that the presence of casts in the urine depends upon the admixture 
of albumin, since they are found in conditions accompanied by albumin; 
and the more abundant the albumin, the more likely it is that casts are 
present. This view seems to be nearly correct. Casts are probably the 
products of an albuminous exudation from the blood-vessels, with the 
addition of the swollen and destroyed epithelia. In almost all cases 
where casts are present, albumin is found in moderate or large amount ; 
but there are undoubtedly cases in which the amount of albumin is small, 
and, it is claimed, may even be entirely absent. The latter is, however, 
doubtful. The amount of albumin may be so small as to escape detection 
by the usual chemical methods employed; but, according to this view of 
their formation, it would seem that a small amount, at least, must be 
present in every case. 

The appearance of casts in the urine is always of the highest diagnos- 
tic importance, and, if found in any amount, they indicate the presence 
of a croupous or parenchymatous nephritis, the more so the larger the 
accompanying amount of albumin. It is asserted that a mere hyperemia 
of the kidneys may suffice to throw casts into the urine, and also that 
casts can be found in small numbers when the kidneys are perfectly in- 
tact. They have been described in cases of gastro-intestinal catarrh, in 

132 



TUBULAR CASTS. 133 

jaundice, acute and chronic anaemia, as well as in nervous affections of 
different kinds, without any accompanying inflammation of the kidneys. 
As they have been found in very small numbers only in all such cases, it 
is an open question whether true casts were seen, or only cylindroids, 
which at times it is almost impossible to distinguish from hyaline casts. 
Since casts are always the products of an inflammatory process, they can 
hardly be found in plain hyperemia of the kidney, unaccompanied by an 
inflammation. 

In order to guard positively against any errors in the diagnosis, it is 
important always to look for other evidences of inflammation in the 
urine, when casts are believed to be present. As soon as they are found, 
the nature of the formations is plain. Great difficulty seems to exist 
sometimes in finding casts, even when they are known to exist, since at 
times they will not settle for a number of hours. If urine is allowed to 
stand for at least six hours and is then carefully decanted, the casts, if 
any are present, will surely be found in the sediment at the bottom of the 
vessel. Attention should also be called to the fact that low magnifying 
powers are unreliable for the detection of casts, and that a power of at 
least 400 diameters should always be used. Another necessary precaution 
is to examine more than one specimen before positively determining as to 
the presence or absence of casts. With a little care, the centrifuge can 
undoubtedly be used, but unless it is of great importance to examine a 
specimen of urine at once, the older method is preferable. 

Casts have been divided in many different ways, but perhaps the sim- 
plest is to divide them into true casts and false or pseudo-casts. The for- 
mer alone denote the presence of a nephritis, while the latter are accidental 
formations. 

I. TRUE CASTS. 

True tube casts are of six varieties. These are: 

1. Hyaline casts. 

2. Epithelial casts. 

3. Blood casts. 

4. Granular casts. 

5. Fatty casts. 

6. Waxy casts. 

Generally speaking, the first three varieties — hyaline, epithelial, and 
blood casts — are found in an acute parenchymatous or croupous nephritis, 
while the last three — i.e., granular, fatty, and waxy casts — are found in a 
chronic parenchymatous inflammation of the kidney. In the first few 
weeks of the inflammation, granular casts rarely appear, fatty and waxy 



134 URINARY ANALYSIS AND DIAGNOSIS. 

casts never; but as soon as the absolutely acute attack commences to 
subside and the inflammation assumes a more subacute form, granular 
casts, first in small, then in larger numbers, are always seen, while the 
hyaline and epithelial casts are still abundant. Fatty and waxy casts 
are secondary products, and are never found until a nephritis has lasted 
for some time, although mixed epithelial and granular casts, commencing 
to become fatty, may be found five or six weeks after the beginning of 
the inflammation. 

All true casts may appear in three distinct sizes, according to the por- 
tion of the uriniferous tubules from which they originate. The narrowest 
casts are those formed in the narrow tubules, the next in size from the 
distal convoluted tubules, while the largest are always formed in the 
straight collecting tubules. Casts from the proximal convoluted tubules, 
those directly arising from the capsule of the tuft, never appear in the 
urine, since they cannot pass the narrow tubules. 

Although not generally admitted, a great prognostic value undoubt- 
edly attaches to the size of the casts. The mildest degrees of the disease 
are usually indicated by casts from the narrow tubules, and a small num- 
ber of casts from the convoluted tubules. Not infrequently pedunculated 
casts are met with ; that is, formations from the place of transition of the 
narrow tubules into the distal convoluted tubules. Casts from the con- 
voluted tubules justify the diagnosis of parenchymatous nephritis in the 
cortical substance. Casts of all three sizes, the largest arising from the 
straight collecting tubules, permit of a conclusion of parenchymatous ne- 
phritis in the whole organ, and upon this condition a very unfavorable 
prognosis can be established. 

Based upon these simple facts, a good or bad prognosis can be given 
in many cases where the clinical features are too obscure to be of any 
practical value; and not infrequently the bad prognosis, which has to be j 
given on account of the presence of many large casts from the straight 
collecting tubules, and which does not at first seem justified by the scar- 
city of clinical symptoms, is soon borne out by the fatal end of the case. 

That, besides these facts, stress must always be laid upon the general 
constitution of the patient, which, as previously explained, can be posi- 
tively recognized by the appearance of the pus-corpuscles, need hardly 
be mentioned again. A careful examination of all the pus-corpuscles 
present in a given case will invariably show how much the constitution 
has been impaired by disease ; the paler the pus-corpuscles the more un- 
favorable the prognosis, and, therefore, the worse the constitution of the 
patient at the time of examination. 

1. Hyaline Casts (see Fig. 65). — Hyaline casts are pale, transparent 
formations of variable length, sometimes of considerable size, and not in- 



TUBULAR CASTS. 



135 



frequently difficult of detection in the urine. Those from the convoluted 
and straight collecting tubules are usually more or less regular, though the 
latter may be very broad; those from the narrow tubules are occasionally 
tortuous or spiral, and at times exceedingly narrow and delicate. As a 
rule, these casts are absolutely structureless, but at times a pale granula- 




Ftg. 65. — Hyaline Casts (X 500). 

Upper row, from convoluted tubules; middle row, from narrow tubules; lowest row, 

from straight collecting tubules. 



tion is noticeable in them, though this is not sufficiently marked to allow 
of their classification as granular casts. Different formations, such as pus- 
corpuscles and fat-globules, may be seen upon them in small numbers, 
but are accidental and do not change the diagnosis. In rare cases these 
casts may appear more solid and of higher refraction, though their hya- 



136 URINARY ANALYSIS AND DIAGNOSIS. 

line character is undoubted, and they must not be mistaken for waxy 
casts. 

When very delicate and pale, it has been advised to color the casts by 
the addition of a drop of iodine-iodide of potash solution (iodine, 1 part; 
iodide of potash, 2 parts; water, 300 parts) upon the slide, which will 
stain them yellow and render them more distinct. This is rarely neces- 




Fig. 66. — Epithelial Casts (X 500). 

Upper row, from convoluted tubules ; middle row, from narrow tubules ; lowest row, 

from straight collecting tubules. 

sary, since a sharp focus, perhaps with the light somewhat shaded, will 
bring them into view quite clearly. In a highly alkaline urine they are 
indistinct, and after a time seem to become lost completely. 

2. Epithelial Casts (see Fig. 66).— True epithelial casts are hyaline 



TUBULAR CASTS. 137 

casts studded with epithelia. The desquamated epithelial tubes which 
are sometimes found in the urine, and represent solid masses of epithelia 
of varying length in the form of casts thrown off from the tubules, can 
hardly be called true casts, although they are usually classified as such. 

Epithelial casts, when present, always denote an acute process; and 
the more pronounced it is, the larger is the number of these casts. They 
vary in size according to their origin, but are never as long as some hya- 
line casts and are usually quite regular. They are of a higher refraction 
than the former, and can be easily found. The number of epithelia seen 
upon these casts varies considerably. Sometimes no more than two, 
three, or four will be found upon a cast, while at other times the cast is 
completely filled with them, though still showing its structure plainly. 
Those from the convoluted and narrow tubules contain spherical or 
slightly irregular epithelia, while those from the straight collecting tu- 
bules usually also contain a number of columnar epithelia. Occasionally 
these casts are of a yellowish color with a slightly increased refracting 
power, owing to their imbibition of the coloring matter of the blood. 

As long as the nephritis is acute, the epithelial casts will have the ap- 
pearance just described, being more or less coarsely granular, but with 
the epithelia perfectly intact. As soon as the inflammation enters the 
subacute or chronic stage, their character changes and fat-globules ap- 
pear. We can then no longer consider them pure epithelial casts. 

3. Blood Casts (see Fig. 67). — The presence of blood casts in the urine 
always shows a hemorrhage within the tubules of the kidney, and, when 
seen in large numbers, the complication is quite grave; but less so in 
children than in adults. The appearance of these casts varies greatly; 
they are usually more irregular than the epithelial casts, their ends more 
or less rounded, and they may be either studded with a varying number 
of red blood-corpuscles without changing their color, or, if they have been 
retained in the tubules for some time, the blood-corpuscles lose their 
shape, and the casts take on the appearance of dark, rust-brown, granu- 
lar clusters. 

Many of these casts may show transitional forms and are more or less 
distinctly colored. They always indicate an acute hemorrhagic process, 
and usually we find either hyaline or epithelial casts, or both, with them. 
Besides these, conglomerations of fibrin, the so-called fibrin casts, are oc- 
casionally found, but, properly speaking, they are not true casts. In the 
rare cases of hemoglobinuria, irregular, dark casts, which appear granu- 
lar and are composed of disintegrated blood corpuscles — the so-called 
haemoglobin casts — may be quite abundant. 

4. Granular Casts (see Fig. 68). — While the three varieties of casts 
just described are always found in acute cases or fresh acute exacerbations 



138 



URINARY ANALYSIS AND DIAGNOSIS. 



of chronic inflammations, granular casts rarely appear in strictly acute 
inflammations. As a rule, they are not formed until a number of weeks 
after the beginning of the disease; but in some cases, especially in chil- 
dren in whom a nephritis develops after contagious diseases, such as scar- 




Fig. 67. — Blood Casts ( X 500). 

C, Casts from convoluted tubules; N, from narrow tubules; S, from straight 

collecting tubules. 

let fever and diphtheria, they may be seen in small numbers one or two 
weeks after the first symptoms of the nephritis have set in. 

Granular casts are either perfectly regular and have sharply defined 
contours, or they are more or less curved, or appear curved at one side 
while they are straight at the other. Their ends are either rounded or 
partly broken, and they may be broader at one place and narrower in 
another — a peculiarity especially pronounced in those from the narrow 



TUBULAR CASTS. 



139 



tubules. Their degree of refraction changes considerably, and they some- 
times appear yellowish, at other times colorless. 

The granulation of these casts varies to a great degree, some being 
coarsely granular, others finely granular, still others partly the former 
and partly the latter. They may appear coarsely granular at both ends, 




Fig. 68. — Granular Casts (X 500). 

C, Casts from convoluted tubules ; N, from narrow tubules ; S, from straight 

collecting tubules. 

finely granular in the centre, or finely granular above and below and 
coarsely granular in the centre, the gradations being many. 

Granular casts are probably due in most cases to a disintegration of 
the kidney epithelia, which will commence after a varying length of time. 
In those cases which have not as yet become chronic, the disintegration 



140 



VEINABY ANALYSIS AND DIAGNOSIS. 



of the epithelia can be studied under the microscope in all the different 
stages. In cases of long duration the granules become changed into 
glistening fat-granules and -globules. 

5. Fatty Casts (see Fig. 69). — True fatty casts are always secondary 
products of epithelial and granular casts, therefore their size and shape 




Fig. 69. — Fatty Casts ( X 500). 

C, Casts from convoluted tubules ; N, from narrow tubules ; *S, from straight 

collecting tubules. 

resemble the former considerably. The substance of all the casts so far 
mentioned is the same, the difference in appearance being given by the 
outer adhering formations. Conglomerations of variously sized, some- 
times large, fatty globules, without well-marked contours, showing their 
original substance, cannot be classed as true casts. 

Fatty casts contain a varying number of small, glistening fat-globules 



TUBULAR CASTS. 



141 



and -granules, which give to the cast a high refraction, the cast being 
either completely or partially filled with them. As they are secondary 
products only, it follows that, even when they are present in small num- 
bers, the diagnosis of a chronic process is justified ; the more so, the more 
completely they are formed. The commencement of their formation can 




Fig. 70.— Waxy Casts (X 500). 

C, Casts from convoluted tubules ; N, from narrow tubules ; S, from straight 

collecting tubules. 

frequently be seen in both epithelial and granular casts, the granules be- 
coming more glistening and highly refractive, and finally changing to 
globules. When the casts are present in large numbers, they always de- 
note a pronounced fatty degeneration of the kidney, as found in the large 
white kidney. 

6. Waxy Casts (see Fig. 70). — Waxy casts are different in their chem- 



142 



URINARY ANALYSIS AND DIAGNOSIS. 



ical nature from hyaline casts; they are characterized by wavy, fluted 
contours, a high refracting power, a more or less yellowish color, and a 
high degree of brittleness. They vary greatly in size, and are always 
more or less irregular, on account of their frequently broken contours. 
Sometimes their wavy, fluted appearance is extremely pronounced, and 
they may resemble regular corkscrew windings. 




Fig. 71.— Mixed Casts ( X 500). 



When all these characteristics are present the diagnosis of a waxy cast 
is plain, and such a cast never appears in acute inflammations, but only in 
chronic processes, which, if the casts are at all numerous, are always in- 
tense. They invariably signify waxy degeneration of the kidney. Some- 
times hyaline casts exhibit spiral windings, and may somewhat resemble 
waxy casts. These spiral windings are probably due to their having orig- 



TUBULAR CASTS. 143 

inated in the spiral portion of the ascending branch of the loop tubule, 
and have no special significance. Such hyaline casts are never of the 
same high refraction as the waxy casts, and a little care is sufficient to 
differentiate them from each other. 

Pure waxy casts may be found studded with different formations, 
which, of course, does not change the character of the cast. At times 
they are of extremely large size, and may then be almost entirely broken 
in different portions. 

7. Mixed Casts (see Fig. 71). — In a large number of cases, when casts 
are present, these casts do not appear in their true form, but may be 
more or less mixed. Any two, three, or four varieties may be so inter- 
mingled as to be difficult of differentiation. The more common of these 
forms will be found in Fig. 71. 

In the first row, the first cast shows an epithelial-granular-fatty vari- 
ety, with the epithelia perfectly intact; while the other casts partly show 
how the epithelia break down and become disintegrated into granules and 
fat-granules and -globules, partly the change of granular into fatty casts. 
The disintegration of the epithelia, in the manner here depicted, is fre- 
quently seen in subacute inflammations. The change of granular casts 
into the fatty kind is seen in chronic processes. 

In the second row, combinations of waxy casts are shown, the first 
being a fatty-waxy; the second, a granular-fatty-waxy; while the third 
and fourth are blood-waxy casts. The first cast in the third row is an 
epithelial-blood cast; the second, a blood-epithelial-granular-fatty cast; 
and the third, an epithelial-granular-fatty-waxy cast. The diagnosis of 
a case does not, of course, become altered by these combinations. 

Other Casts. — Besides these six varieties of casts, the mucus-casts or 
cylindroids, previously described, are occasionally placed among the true 
casts; that they do not have any special significance has already been 
stated. They may contain a varying number of fat-globules, but their 
striated, irregular appearance is sufficient to clear up the diagnosis. 

Again, a separate variety of casts is described as being derived from 
the seminal tubules. These casts are said to resemble hyaline casts, but 
to differ from them in their larger size, greater breadth, and greater irreg- 
ularity. They are, however, nothing but cylindroids, and, as such, have 
no special significance. 



144 



URINARY ANALYSIS AND DIAGNOSIS. 



II. FALSE OR PSEUDO-CASTS. 

False or pseudo-casts are not infrequently found in the urine, and 
have no connection whatever with diseases of the kidney. These forma- 
tions are mostly conglomerations of different substances upon mucus- 
threads or -casts, or accidental formations in the shape of casts. When 
true casts, especially of the hyaline variety, are present, together with an 
abundance of urates, the latter may undoubtedly be found upon the casts 
to such a degree as to render a diagnosis of the original cast doubtful. 

Urate Casts (see Fig. 72). — Among these formations, conglomerations 
of urates, sometimes called uric-acid casts — although uric acid, as such. 



m 




Fig. 72. — Casts of Ammonium Urate and Sodium Urate (X 500). 



rarely enters into their structure — as well as casts of sodium urate, are 
not infrequently found. The former, consisting of conglomerations of 
ammonium urate, are described as occurring only in infants, and forming 
in them small, reddish-brown masses, apparent to the naked eye; but 
they are also seen in adults, although very rarely. Formations of sodium 
urate, resembling casts, may at times be mistaken for granular casts; but 



TUBULAR CASTS. 



145 



they have the characteristic yellowish-brown color of sodium urate, and 
show no outlines in many cases. When the masses of sodium urate are 
not heavy, mucus-threads or -strings can be distinctly seen underlying 
them. Besides these, we may also see such formations composed of gran- 
ules of sodium urate changing to globules and dumb-bells. When the 




Fig. 73. — False or Pseudo-casts (X 500). 
B, Bacterial casts; P, pus casts; Ft, fat cast; F, fibrin casts. 

change has advanced to a considerable degree, some of these formations 
may resemble disintegrated blood- or haemoglobin casts, and great care 
must be taken not to mistake such urate casts for blood casts. Here, 
too, the absence of a contour, as well as the color of the urates, will be 
sufficient for a diagnosis. 

Among the other pseudo-casts, the more common are bacterial, pus, 
fat, and fibrin casts (see Fig. 73). 
10 



146 URINARY ANALYSIS AND DIAGNOSIS. 

Bacterial Casts. — Bacterial casts are of frequent occurrence, especially 
when the urine has been allowed to stand in a warm room for twelve hours 
or more, so that a large number of bacteria have developed. They un- 
doubtedly resemble granular casts so much as sometimes to require a 
sharp focusing for their differentiation. They may vary considerably in 
size, but their outlines are pale and more or less irregular, and the}^ are 
composed of masses of micrococci, not of granules. They have no signifi- 
cance whatever, except when found in perfectly fresh urine as an aid to 
diagnosis, where they are most likely to be seen in severe inflammatory 
or suppurative processes. As a rule, the micrococci become deposited 
upon mucus-threads. In order to clear up their diagnosis, it may, in rare 
cases, be necessary to add a drop or two of some strong mineral acid or 
alkali, to which they will be seen to have a great resistance. 

Pus Casts. — Pus casts— that is, cast-like conglomerations of pus-cor- 
puscles, usually upon mucus — are found in some cases. The pus-corpus- 
cles may be massed together, with no outlines visible, or they are more 
loosely arranged, and may contain a number of small fat-globules. Pus- 
corpuscles may, of course, be found in small numbers upon different true 
casts, such as hyaline or epithelial, but such formations cannot be classed 
as pus casts. 

Fat Casts. — Pseudo-fat casts are rare, but have been found in a few 
cases of so-called lipuria. They consist of large fat-globules, of a very 
high refraction, and occasionally containing margaric-acid needles. Again, 
a number of extraneous fat-globules upon mucus-threads have been seen; 
but these have a yellowish color, and can easily be differentiated. 

Fibrin Casts. — Lastly, fibrin casts may be found in cases of hemor- 
rhage. They may be of large size, have irregular, more or less sharply 
denned contours, and are of a yellowish or yellowish-brown color. They 
consist of small, wavy, irregular fibres, and never occur without the pres- 
ence of characteristic strings or bands of fibrin. In cases of hemorrhagic 
parenchymatous nephritis, true blood casts are always associated with 
them. 

Besides haemoglobin, which may occur in the form of casts, two other 
varieties of pseudo-casts have been described, namely, pigment and cho- 
lesterin casts. Peyer has seen one specimen of each of these, but they 
are the rarest formations in urine. 



CHAPTER XIV. 

MICRO-ORGANISMS AND ANIMAL PARASITES. 
I. MICRO-ORGANISMS, OR FUNGI. 

Perfectly fresh urine normally does not contain any micro-organ- 
isms and can be considered sterile when obtained directly from the bladder; 
it may, however, be contaminated, when voided, by bacteria present in 
the urethra and especially the vagina. When allowed to stand, bacteria 
usually develop in a short time, even in originally sterile urine. In 
pathological conditions, on the other hand, bacteria may be present in 
large numbers when voided; such urine is always more or less turbid, 
and here the designation bacteriuria can be used. 

The development of bacteria in urine may be slow or rapid, depending 
partly upon the reaction and partly upon the temperature. In an alka- 
line urine they develop rapidly, and in a warm temperature are usually 
found in large numbers one or two hours after the urine is voided. 
Bacteria present when the urine is passed may be derived from any 
portion of the genito-urinary tract or may be transported through the 
blood stream. 

Micro-organisms seen in urine are divided into non-pathogenic and 
pathogenic. The former may belong to either the class of mould fungi, 
to that of yeast fungi, or to that of fission fungi; while the latter belong 
to the class of fission fungi. 

Non-pathogenic Micro-organisms. 1. Mould Fungi. — Mould fungi, or 
hyphomycetes , found in urine are either oidium, penicillium glaucum, or 
one of the aspergilli, the latter being comparatively rare. These fungi 
will be seen only in acid urine, or urine which was originally acid, even 
though it has become alkaline. 

The most common of the hyphomycetes is the oidium lactis, com- 
posed of conidia and mycelia (see Fig. 74). It easily develops in small 
numbers in urine of a highly acid reaction, and can be seen with the 
naked eye, in the form of whitish masses, only when present in large 
amount. Such urines contain a varying number of small globules, in 
which frequently a central so-called vacuole is observed, together with 
threads of mycelia, either narrow and short, or quite large and branching. 
The globules are the spores or cmidia, and care must be taken not to 

14/ 



148 



UBINABY ANALYSIS AND DIAGNOSIS. 



mistake them for red blood-corpuscles or even fat-globules, which they 
may resemble. They vary in size, and can generally be distinguished by 
the central vacuole. The threads are the mycelia, which are, as a rule, 
coarsely granular and segmented, and contain a number of spores. They 




Fig. 74.— Oidium Lactis (X 500). 

may be mistaken for mucus, connective tissue, or even granular casts 
from the narrow tubules, from all of which they differ, however, by their 
peculiar, rather high refraction. 

Besides the oidium lactis, both the penicillium glaucum and different 
varieties of aspergilli may be found in the urine, the former being quite 
common (see Fig. 75). The diagnosis of penicillium or aspergillus can be* 
made only by the characteristic fruit-bearer or sporangium arising fromn 
the hypha. In penicillium glaucum, the most common mould fungus, thee 
hyphse divide and subdivide into thread-like formations — the basidia and 
sterigmata — the ends of which latter are surmounted by a number of 
spores or conidia. In the aspergilli no division takes place, but the hypha 
terminates in a spherical or club-shaped vesicle, from the periphery ol 
which a number of short fiask-iike formations — the sterigmata — are vis- 
ible, each of which contains a single spore upon its upper end. 

2. Yeast Fungi (see Fig. 76). — The yeast fungi, or saccharomycetes , an 
found in acid urine, and are most frequently seen in those containing 
sugar, where they may be present in large numbers. They consist of va 



la 



MICRO-ORGANISMS AND ANIMAL PARASITES. 149 

riously sized globules or cells, the larger of which contain a smaller glob- 
ule or nucleus. They never form mycelia, but multiply by sprouting or 
budding. The globules have an oval or round shape, he either singly, in 
twos, or in groups of different sizes, and are frequently beaded. In the 




Fig. 75. — Penicillium Glattcttm and Aspergilli (X 500). 

The upper half of the drawing shows the penicillium glaucum, the lower half different 

varieties of aspergilli found in urine. 

larger globules the process of budding can be plainly seen. The smaller 
globule, or daughter-cell, sprouts out from the larger or mother-cell, be- 
comes an independent formation, grows, and, in its turn, forms a mother- 
cell. These globules may undoubtedly resemble blood-corpuscles, but 



150 URINARY ANALYSIS AND DIAGNOSIS. 

their irregular size and shape, together with the presence of the nucleus, 
will be sufficient to differentiate them. 

3. Fission Fungi (see Fig. 77) . — The fission fungi, or schizomycetes, are 
rarely seen in highly acid urine, but frequently in urine which is becom- 
ing alkaline or has already undergone an alkaline change and is showing 




Fig. 76. — Saccharomycetes (X 500). 

putrefaction. When they are present in large numbers the urine is always 
cloudy, and both cocci and bacilli may be found. Of the former, the most 
numerous are large cocci, lying either irregularly or in small chain form — 
the micrococcus urece. This coccus, to a great degree, causes ammoniacal 
decomposition of the urine, the urea being transformed by it into ammo- 
nium carbonate. In urines containing pus-corpuscles in large numbers, 
both staphylococci and streptococci pyogenes — the former being small cocci 
grouped in variously sized, irregular bunches, and the latter in longer or 
shorter chains — will also be seen. Besides these, the so-called zooglcea 
groups of cocci — cocci arranged in more or less regular masses — envel- 
oped in a colorless, gelatinous capsule, may also be found, as well as large 
cocci, the sarcince urince, which are united into packets resembling corded 
bales of cotton, and are usually smaller than the sarcinse found in sputa. 
Staphylococci and streptococci pyogenes are pathogenic, and may be 
found in any inflammatory condition. 

Bacilli are usually present in varying numbers with the cocci, and are 
of different sizes, some of the small ones occasionally lying in twos, being 
formerly called bacterium termo, one of the varieties of putrefactive bacilli 
which cause ammoniacal decomposition of urine. Others, among them 
the bacillus or bacterium urece, are larger, and there are still others larger 



MICRO-ORGANISMS AND ANIMAL PARASITES. 151 

than the latter, among which the bacillus subtilis, or hay bacillus, is com- 
mon. These bacilli are found to have a varying amount of motion, some 
being very active, others only slightly movable, and some without motion. 
Besides the single bacilli, the urine not infrequently contains threads, 
composed of individual rods — the leptothrix threads — which may be 
quite abundant. There are cases of chronic cystitis, in which the urine, 
when voided, contains leptothrix threads in large numbers, and in which 
the cystitis seems to be caused by the leptothrix; these threads may lie 
upon as well as between the epithelia. In such cases whitish masses of 
small size are found in the freshly voided, cloudy urine, and when exam- 
ined under the microscope are seen to consist of conglomerations of blad- 
der epithelia with many leptothrix threads. Cases of this kind may last 
for many years, and frequently recur in spite of all local treatment. 



//•/ • •. v..: ' /; . -.• 



r*x'/> 



P%v7..-v</.'^/.:>;-^-v^v: 




Fig. 77. — Schizomycetes ( X 500). 
B, Bacilli; St, streptococci ; Sa, staphylococci ; L, leptothrix ; MU, Micrococcus urese; 
Z, zooglcea; S, sarcinae. 

Pathogenic Schizomycetes. — Among the pathogenic bacteria, the 
most important are undoubtedly the gonococci and tubercle bacilli, which 
are not infrequently found in urine, and for which careful search must, 
when necessary, be made. For the detection of these, it will always be 
necessary to color the specimens, and the mode of procedure is the fol- 
lowing: Select the thickest portion of the urinary sediment, best ob- 
tained by the use of the centrifuge, or the filaments, if any are present, 
as will be the case in chronic gonorrhoea, and by means of a sterilized 



152 URINARY ANALYSIS AND DIAGNOSIS. 

needle spread carefully over perfectly clean cover glasses, taking never 
less than two, but preferably three or more. Allow the glasses to dry 
thoroughly, and draw them through the flame of an alcohol lamp or a 
Bunsen burner in a moderately quick manner, specimen side upward, 
three times, partly to fix the specimen upon the cover glass, and partly 
to coagulate the albuminous substances present. Then color the speci- 
men with an aniline color, either fuchsin, methylene blue, or gentian 
violet. 

Gonococci. — In searching for gonoccoci in the urine, the cover glasses 
are best colored, for a few seconds to one or two minutes, either with a 
plain watery fuchsin solution, made by taking one part of a concen- 
trated alcoholic fuchsin solution ione part of fuchsin in substance to four 
or five of absolute alcohol) to eight, ten, or twelve parts of distilled water ; 
or with a methyl ene-blue solution — twenty to twenty-five drops of a con- 
centrated alcoholic solution to one ounce of water, to which one drop of 
a five per cent caustic-potash solution has been added. Methylene-blue 
solution may also be made by taking 30 parts of a concentrated alcoholic 
methylene-blue solution and 100 parts of 0.01 per cent caustic potash; 
this is Loeffler's alkaline methylene-blue solution. Any one of these so- 
lutions, if carefully made, will keep a long time, and is always ready for 
use. 

After having passed the cover glasses through the flame, as just de- 
scribed, a small amount of the coloring solution is dropped upon the 
specimen and allowed to remain for from a few seconds to a minute or 
two, the former being sufficient when fuchsin is used, the latter being 
necessary when methylene blue is employed. After coloring, the cover 
glass is rinsed in water, the lower surface dried, and the specimen either 
at once mounted upon a slide and examined in water or dried and mount- 
ed in a drop of Canada balsam. 

Although the gonococci can be seen with a power of 500 diameters, it 
will always be better to use a power of at least 700 or 800 diameters and 
an Abbe condenser. In specimens so prepared, the gonococci, as well as 
the nuclei of the pus-corpuscles and epithelia, are colored. The pus-cor- 
puscles will be seen to contain one or more nuclei. 

In cases of acute gonorrhoea (see Fig. 78) the gonococci, or micrococci 
gonorrh&ce, are found in large numbers in the urine, not as numerous as 
in the gonorrheal pus taken directly from the orifice of the urethra, but 
still very abundant. They are seen both in the pus-corpuscles and lying 
free in variously sized groups. The pus-corpuscles are numerous, and mu- 
cus-threads in small numbers are always present. Urethral epithelia are 
also usually found, and may contain groups of gonococci. 

Gonococci were first discovered by Neisser in the year 1879, and cul- 



MICRO-ORGANISMS AND ANIMAL PARASITES. 153 

tivated by Bumm in 1885. They are, as a rule, found in twos, either sin- 
gly or in groups, with the adjacent surfaces flattened and separated by a 
colorless interspace, giving the so-called biscuit shape. The more or less 
regular groups of diplococci are found either entirely within the pus cor- 
puscles or epithelia, or lying entirely free, but never half-way within and 
half-way free, though large groups, completely filling the pus-corpuscles, 
may slightly overlap the periphery. Again, no matter how completely 
the pus-corpuscles are filled with them, the nucleus or nuclei usually re- 




® w tlf 9 



Fig. 78. — Acute Gonorrhoea (X 700). 
G, Groups -of gonococci; GP, pus-corpuscle containing gonococci; MS, mucus- thread. 



main free, though here, again, individual cocci may be found upon the 
periphery of the nucleus. These features, though perhaps not absolutely 
characteristic, are sufficiently so for all practical purposes. 

If any doubt remains about their character, a few specimens should 
be colored with a gentian-violet solution, either a one per cent aqueous 
solution (gentian violet 1 part, distilled water 99 parts), or an aniline 
water solution, made by adding 5 parts of a concentrated alcoholic solu- 
tion to 100 parts of aniline water (aniline oil 1 part, distilled water 20 
parts, and filter) for a few minutes and subjected to Gram's solution 
(pure iodine 1 part, iodide of potash 2 parts, and distilled water 300 
parts) for one or two minutes. The specimens are now washed in alcohol, 
then rinsed in water and recolored with a one or two per cent vesuvin 
solution (vesuvin 1 or 2 parts, distilled water 99 or 98 parts) for a few 



154 



URINARY ANALYSIS AND DIAGNOSIS. 



minutes, again rinsed in water, and either examined in water or dried and 
mounted in Canada balsam. 

When subjected to this method, the gonococci have lost their original 
violet stain and have taken up the vesuvin, being, therefore, colored 
brown. This method at once differentiates them from the staphylococci, 
which retain their violet color. If all the features enumerated, especially 
their characteristic grouping within the pus-corpuscles, and the loss of 
their violet color by the last-named method, are present, no doubt what- 
ever will exist as to the character of the cocci. 

In acute cases of gonorrhoea the search for gonococci is very easy ; but 
this becomes a more difficult matter in the chronic cases, where only a 




Fig. 79. — Chronic Gonorrhoea (X 700). 
GP, Pus-corpuscles containing gonococci; GE, epithelium from the prostate gland 
containing gonococci; St, pus-corpuscles containing Staphylococci pyogenes; Sr, Strep- 
tococci pyogenes; MU, Micrococcus urea?; MS, mucus- threads ; MP, mucus-corpuscle. 



small number of filaments may be found in the urine. Frequently it is of 
the utmost importance to determine the presence or absence of gonococci 
in such cases, and the filaments are subjected to the methods just described 
and carefully examined. In this work it is never advisable to depend 
upon a power of 500 diameters, but higher powers, even a homogeneous 
immersion lens, should be used, and a large number of specimens care- 
fully examined. The features found in such a filament, containing gono- 
cocci, are shown in Fig. 79. 



MICRO-ORGANISMS AND ANIMAL PARASITES. 155 

Pus-corpuscles are never so abundant in these cases as in the acute, 
and may even be quite scanty, but mucus-threads as well as corpuscles 
are numerous; epithelia from the urethra, and usually from the prostate 
gland, will also be seen. The gonococci are always found in smaller num- 
bers, but only singly or in small groups, and the cocci seen should never 
be diagnosed as such unless some are found within the pus-corpuscles. 
Besides gonococci, such filaments always contain irregular groups of 
staphylococci; these may be either free or in groups, lying partly within 
pus-corpuscles and partly outside. In some cases streptococci, usually in 
rather small chains, are also present, as well as the micrococcus urea? in 
chains or irregular small groups. 

Occasionally it may be necessary to use culture media, although it is 
difficult to grow gonococci from urinary sediments. For this purpose either 
blood-serum agar or Loeffler's blood serum may be used, though some 
prefer media made with hydrocele or ascitic fluid and agar-agar. Even 
at best the growth of gonococci is slow and never very heavy. 

Other Cocci. — Besides gonococci, other pyogenic cocci, both staphylo- 
cocci pyogenes and streptococci pyogenes, are found in urine, but, as 
may be expected, only wherever there are large numbers of pus-corpus- 
cles; they, therefore have little practical significance. The staphylo- 
cocci are the staphylococcus pyogenes aureus, albus, and citreus, which 
can be differentiated only by culture methods. Besides the streptococ- 
cus pyogenes, a streptococcus, wdiich cannot be distinguished from it, but 
has been described by Fehleisen as being the cause of erysipelas, may be 
found in all cases of erysipelas in which a nephritis is at the same time 
present. Micrococci have also been seen in the urine in septic processes, 
as well as in endocarditis. 

Tubercle Bacilli. — The presence of tubercle bacilli in moderate num- 
bers in the urine is always a symptom of tuberculosis somewhere in the 
genito-urinary tract. Its exact location can easily be determined by the 
characteristic epithelia. As a rule, they will be found in larger numbers 
only when a suppurative or an ulcerative process exists; and whenever 
the diagnosis of a suppuration or an ulceration can be made from the dif- 
ferent features found in the urine, together with an impaired or broken- 
down constitution, it will be best to examine for tubercle bacilli, even 
though distinct clinical symptoms of a tubercular process have not as yet 
developed. 

The search for tubercle bacilli in the urine is by no means an easy one, 
and many drops may have to be examined before arriving at a definite 
conclusion. The appearance of the urine is no criterion, since bacilli may 
be present in small numbers in rather clear urine, though, as a rule, it 
will be more or less turbid. They can be found in either an acid, neutral, 



156 URINARY ANALYSIS AND DIAGNOSIS. 

or alkaline urine, but the presence of a large number of salts renders their 
detection still more difficult. In such cases it is advisable to dissolve the 
salts with a solution composed of 1 part of borax, 1 part of boric acid, 
and 25 parts of water, which is simply added to the sediment. The thick- 
est portion of the sediment only should be used for the preparation of 
cover-glass specimens, and here the use of the centrifuge offers an un- 
doubted advantage, the bacilli being more easily discovered in a centri- 
fuged than in a non-centrifuged urine, since the centrifuge throws down 
all bacteria in larger numbers than is the case with urine which has been 
allowed to settle for a number of hours. 

The methods employed for detecting tubercle bacilli are numerous, 
but the best are the Koch-Ehrlich-Weigert aniline water and the Ziehl- 
Neelsen carbolic acid water methods. Whether fuchsin or gentian violet 
is used with the former method is perfectly immaterial. An aniline 
water fuchsin solution is made by adding enough of a concentrated alco- 
holic fuchsin solution to aniline water until saturation takes place; that 
is, until a distinct film appears at the top of the solution. This will 
usually be 1 part of the alcoholic solution to 6, 8, or even 10 parts of 
aniline water. The aniline water is prepared by thoroughly mixing 1 part 
of aniline oil with 20 parts of distilled water, and filtering through a 
double layer of filter paper. This solution must be perfectly clear. The 
cover glasses, which, when dried, have been passed through the flame, 
are now dropped upon the solution, specimen side downward, so as 
to float, if possible, and allowed to remain in it for twelve hours if 
kept at the temperature of the room, or forty minutes if the solu- 
tion is kept warm. It is not advisable to heat the cover glasses over 
the flame for a few minutes after having dropped the coloring solu- 
tion upon them, as such specimens are usually not as clear as they 
should be. 

It has been shown bj^ Koch that while tubercle bacilli take on the col- 
oring matter slowly, they are then not readily decolorized, in contradis- 
tinction to most of the other bacteria, which will quickly lose their color 
when subjected to the action of strong acids. The cover glasses, after 
being colored, are therefore placed into a strong acid solution, preferably 
a twenty-five per cent nitric acid, for a few seconds or half a minute, and 
are then thoroughly washed in a sixty per cent solution of alcohol until 
all color has disappeared, rinsed in absolute alcohol and in water, and 
may either be examined at once or, better, are recolored with methylene 
blue, again rinsed in water, and examined in water or Canada balsam. 
The tubercle bacilli, if any are present, will now be seen in the form of 
red rods, while all other features in the specimen are colored blue. In- 
stead of aniline fuchsin, aniline gentian violet can be used, and vesuvin 



MICBO-ORGANISMS AND ANIMAL PABASITW. 157 

employed as a recoloring agent. Muriatic or sulphuric acid may be used 
instead of nitric acid. 

A specimen of tuberculosis of the kidney, colored in this manner, is 
shown in Fig. 80. The features which can easily be recognized are tuber- 
cle bacilli in moderate numbers, pus-corpuscles, epithelia from the convo- 
luted tubules of the kidney, epithelia from the pelvis of the kidney, mu- 
cus-threads, mucus-corpuscles, and various cocci. 

Although specimens prepared with an aniline water solution give ex- 
cellent results, there is one objection to this method, which is that the so- 




Fig. 80. — Tuberculosis of the Kidney (X 650). 
TB, Tubercle bacilli ; PC, pus-corpuscle ; CE, epithelium from convoluted tubules of 



kidney; PE, epithelium from pelvis of kidney: 
puscle. 



MS, mucus-threads; MC, mucus-cor- 



lution does not keep, and has to be prepared fresh every week. Many 
bacteriologists, therefore, prefer to use Ziehl-Neelsen's carbolic acid fuch- 
sin method. The solution is prepared by taking 90 parts of a five per 
cent carbolic-acid solution, 10 parts of alcohol, and 1 part of fuchsin in 
substance. This is undoubtedly the simpler method, and gives good re- 
sults as long as the solution is not too old. With it the specimens need 
not be colored longer than one or two hours when kept at the temperature 
of the room, or ten minutes when dropped in a warm solution. The de- 
colorizing and recoloring processes are exactly the same as with the 
Koch-Ehrlich-Weigert method. 

Since examination for tubercle bacilli in urine is not an easy matter, 
it is invariably best to use those methods which will yield uniformly good 
results, and not to hasten the process of coloring. With the two methods 



158 



UBINABY ANALYSIS AND DIAGNOSIS. 



just described, the tubercle bacilli can always be detected if present, 
though they may be very scanty and found only after a long and patient 
search. 

Care must be taken not to mistake the harmless smegma bacillus, 
which is frequently present in the urine, resembles the tubercle bacillus, 
and is also resistant toward acids, for the tubercle bacillus. The smegma 





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Fig. 81. — Bacterium Coli Commune (X 600). 



bacillus, however, does not resist absolute alcohol for any length of time, 
so that, when its presence cannot be excluded, it is best to subject the 
specimen for one-half hour or longer to alcohol after being treated with 
the acid. The tubercle bacillus is not affected by the alcohol. 

In doubtful cases animal inoculations must be made, a small amount 
of the sediment being injected into the abdominal cavity of a guinea-pig. 
If the sediment contained tubercle bacilli, tuberculosis will develop in the 
animal in from three to five weeks. The cultivation of tubercle bacilli 
from the urinary sediment does not give satisfactory results. The use of 
tuberculin injections to determine the presence or absence of tuberculo- 
sis is also recommended. 

Typhoid Bacilli. — Among the other pathogenic bacilli found in urine, 
the typhoid bacilli have been discovered in large numbers in cases of ty- 
phoid fever, though never at the commencement of the disease, and they 
are not, therefore, of much practical value for the diagnosis. Poniklo, in 
the year 1892, was the first to call attention to the presence of typhoid 
bacilli in the urine, and since then the bacilli have been found bv differ- 



MICRO-ORGANISMS AND ANIMAL PARASITES. 159 

ent observers. In most cases described, the evidences of a more or less 
pronounced nephritis or of a hemorrhage were also present. The bacilli 
may persist in the urine for weeks and even months, and may be ex- 
tremely abundant. 

Bacterium Coli Commune. — The bacterium coli commune (see Fig. 81) 
is not infrequently present in urine, especially in pronounced inflamma- 
tions, such as nephritis, pyelitis, and cystitis; it may be found in large 
numbers, and seems to be a rather common cause of cystitis. This bac- 
terium is a short, thick rod, found also in twos, small chains, and groups. 
It has a moderately active motion. In the year 1895 Pluym and Laag 
described it as the sole cause of a urethritis which gave all the symptoms 
of a gonorrheal infection, in which gonococci were entirely absent, but 
the bacterium coli commune was found in large numbers, lying mostly 
within the pus-corpuscles and epithelia. 

Other bacilli have also been described as being present in various dis- 
eases of the geni to-urinary tract, but they are of no diagnostic value. 

Actinomyces. — The fungus known as actinomyces (see Fig. 82) is of 
rare occurrence in the urine, but is undoubtedly found in actinomycosis 




Fig. 82. — Actinomyces ( X 500). 

of the internal organs, where the disease affects the genito-urinary tract. 
The classification of this fungus has long been undecided, though later 
researches place it among the fission fungi. 

The fungus consists of variously sized conglomerations of highly re- 
fractive, irregular, club-shaped masses. The club-shaped, cylindrical, or 



160 



TJBINABY ANALYSIS AND DIAGNOSIS. 



pear-shaped masses terminate toward the centre in a point or fibrilla, 
which loses itself in a mass of granules, amid other similar fibrillse. The 
individual club-shaped elements greatly vary in length, but all terminate 
in the centre. 

The urine from which the accompanying drawing was made was tur-* 
bid when passed and gave all the macroscopical evidences of a chronic 
cystitis. It contained a few small granular masses which proved to be 
actinomyces. The features present under the microscope were numer- 
ous, and conclusively showed a chronic ulcerative process in the bladder. 
There were pus-corpuscles in large numbers ; epithelia from the bladder, 
especially cuboidal and columnar; numerous connective- tissue shreds; 
fat-granules and -globules; large zoogloea masses; mucus- threads and 
-corpuscles, and the actinomyces fungus, which was perfectly characteris- 
tic, so that the diagnosis of a chronic ulceration of the bladder, due to 
actinomyces, could easily be made. The reaction of the urine was alka- 
line. 

II. ANIMAL PARASITES, OR ENTOZOA. 

Trichomonas Vaginalis (see Fig. 83). — Of all the animal parasites, the 
most common is the trichomonas vaginalis, which belongs to the class of 
infusoria. It occurs in the urine of females, being a frequent but per- 




Fig. 83. — Trichomonas Vaginalis ( X 500). 

fectly harmless inhabitant of the mucosa of the vagina in cases of leucor- 
rhcea. Although it has no pathological significance, its occurrence and 



MICRO- ORGANISMS AND ANIMAL PARASITES. 161 

shapes must be known, since it otherwise might be mistaken for different 
formations, especially when small. 

Trichomonas is of an oval or somewhat irregular form, and usually has 
a tail-like extremity. This extremity, mostly of the same size as the body 
or a little longer, may occasionally be three or four times that size, of con- 




Fig. 84. — Portions of Echinococcus (X 400). 

siderable thickness, and striated. It may, however, be nothing but a 
small filament, like a flagellum. In the interior of the body one, two, or 
more small formations, similar to nuclei, may be seen. In many cases one 
or more cilia are given off from one extremity or side. 

Echinococci (see Fig. 84). — These entozoa, although rare, do occasion- 
ally occur in the urine, and may either have developed directly from the 
urinary organs or have ruptured from some neighboring organ. The 
characteristic parts of the echinococci found in the urine are the hooklets 
as well as portions of the membrane; scolices may also be found. 

The echinococci cysts, as such, will never be seen in the urine, and in 
a suspected case it may become quite difficult to find the characteristic 
portions. The scolices are small, usually round, and supplied with a 
wreath of hooklets. The individual hooklets do not vary in size to a great 
degree, and their shapes, although differing somewhat, are more or less 
identical. Parts of the membrane which have a concentric striation may 
at times be present. In the specimen from which the illustration was 
11 



162 



URINARY ANALYSIS AND DIAGNOSIS. 



taken, the different portions here shown could be found only after pa- 
tient search, but were characteristic. 

In all cases in which parts of the echinococci are found in the urine, 
evidences of a hemorrhage or an ulceration, or both, will be present. As 
a rule, red blood-corpuscles are numerous, together with epithelia and 




Fig. 85. — Ova of Distoma Haematobium ( X 500). 

connective-tissue shreds from the organ in which the cysts are located, 
Pus-corpuscles are usually abundant. When the echinococci have directly 
developed in the urinary organs, the kidney is the general location, and 
epithelia from both the convoluted and straight collecting tubules ard 
present. 

Distoma Hcematobium (see Fig. 85). — The parasite distoma ha?mat&- 
bium, or Bilharzia hamatobia. so called from Bilharz, who first described 
it, has probably never been found in the urine, but its eggs do occur in 
some cases. It is common in hot climates, especially in Egypt, and is 
found in the portal vein and its branches, the splenic and mesenteric veins, 
as well as in the venous plexuses of the rectum and urinary bladder. 

In our climate distoma haematobium is rarely found, but does occur. 
A case of this kind has been described by Brooks and Sondern, who found 
the eggs in the urine in considerable numbers. The illustration was taker 
from this urine, and in every drop examined a dozen or more of the ov£ 
were present. They have an oval or flask-like shape, are large, and tapei 
considerably at one extremity, the other being rounded. They consist oi 
a moderately thick, highly refractive capsule, are coarsely granular, anc 
contain quite a number of small, roundish, granular bodies within i 
membranous formation. 

When these ova are found in the urine, blood-corpuscles, pus-corpus 
cles, and epithelia, usually from the bladder, are seen, showing a hemor 



MICRO- OR&ANimS AND ANIMAL PARASITES. 103 

rhage or inflammation of the bladder. In most cases fat-globules and 
-granules are also present in considerable numbers. The parasites may 
invade any portion of the urinary tract, especially the ureters and pelves. 
Filaria Sanguinis Hominis (see Fig. 86) . — This parasite is also of rare 
occurrence in our climate, but common in other climates, as in the West 
India Islands, Egypt, China, and Japan. It seems to be transferred to 
human beings through mosquito bites, and may be extremely abundant 
in the blood; in urine it may be found in varying numbers in such cases. 




Fig. 86. — Filaria Sanguinis Hominis ( X 600) 

It consists of a cylindrically shaped body, a short, rounded head, and a 
long, thread-like, pointed tail. It is granular and frequently striated. 
When the parasite appears in the urine, it may cause either severe 
^ ha3maturia or the condition known as chyluria, or more frequently both. 



164 



URINARY ANALYSIS AND DIAGNOSIS. 



It is claimed that it may be present in perfectly clear urine, but this must 
be very rare, since, as a rule, the urine presents a milky appearance when 
voided, and upon examination is found to contain a large amount of fat, 
in the form of small globules and granules, as well as the evidence of a 
more or less pronounced hemorrhage. Pus-corpuscles, as well as different 
epithelia, are usually present in small numbers. 

When such a milky urine, denoting chyluria, is examined, filaria must 
always be looked for, since the parasite is almost invariably the cause of 
this condition. It may be present in large numbers in the urine, so that 
there will be no difficulty in finding it ; but, on the other hand, it may be 
scanty. In examining for filaria, it is advisable to take the first urine 
voided in the morning, since it is a well-known fact that the parasite is 




Fig. 87. — Ova and Portion of Ascaris Lumbricoides (X 500). 



active at night, or rather during the resting hours of the patient, and can 
then be found in large numbers in the blood, while it is quiescent during 
the working hours and cannot be found. 

Ascaris Lumbricoides (see Fig. 87). — Although in rare instances only, 
the round worm, ascaris lumbricoides, of such common occurrence in the 
intestinal tract of children, may be found in the urine, having passed into 
the bladder through the urethra. Portions of the parasite and a number 
of ova will then be present in the urine. 

The urine from which the illustration was taken gave all the features 
of a severe acute catarrhal cystitis. It contained a small number of mi- 
nute particles, which proved to be the ova; also a part of the body of an 
ascaris. The ova, of a yellowish-brown color, are round formations, en- 
closed in a thin, irregular capsule and a somewhat thicker membrane; 



MICRO-ORGANISMS AND ANIMAL PARASITES. 165 

the interior is coarsely granular and contains a nucleus. The parasite 
itself is of considerable size, has a cylindrical body, a narrower, tail-like 
extremity, and a head consisting of three papilliform nodules; it is found 
in the urine only in very rare instances. 

Other Parasites. — Other parasites which may possibly be found in the 
urine are the strongylus gigas, oxyuris vermicularis , and the cercomonas 
urinarius. The strongylus gigas resembles the ascaris lumbricoides, al- 
though it is much larger, and its head contains six papilliform nodules 
instead of three. The oxyuris vermicularis is a small, thread-like forma- 
tion, and the cercomonas urinarius a small infusorium, which consists of 
an oval, granular body, and contains a number of cilia. These parasites 
are extremely rare and of no practical importance. 



CHAPTER XV. 

EXTRANEOUS MATTERS. 

Extraneous matters are common occurrences in urinary sediments, 
and must be well known, as they might frequently lead to errors in diag- 
nosis. Their presence in the sediment may be due to many causes, such 
as exposure to air, from which various objects may fall into the urine, 
pouring the urine into bottles which are not perfectly clean, the use of 
salves or dusting-powders for the genital organs, or admixture of particles 




Fig. 88. — Cotton Fibres (X 500). 



from the faeces. Many of these formations are characteristic enough, but 
others may closely resemble various features of normal or pathological 
urine, from which they must be carefully differentiated. 

The different fibres of cotton, linen, silk, and wool are frequently 
found in the urine. 

Cotton Fibres (see Fig. 88). — Cotton fibres are coarse, somewhat wavy 
and twisted. They are highly refractive, their edges being more compact 
than the centre. The central portion may appear slightly folded, and 

166 



EXTRANEOUS MATTERS. 167 

often shows irregular markings. When the fibres are very small the 
diagnosis must be made from the wavy, compact appearance. 

Linen Fibres (see Fig. 89). — Linen fibres are variously sized, some- 
times broad, and at other times narrow. They are composed of smaller 




Fig. 89. — Linen Fibres (X 500). 

fibrilla?, which, although quite refractive, are less so than cotton fibres. 
At different parts of the fibre, irregular transverse breaks are seen, which 
are caused by the process of hatchelling. The finest fibrillge will be found 
broken off in a very irregular manner from the surface of the main fibre, 
being either long or short, and at times branching in different directions. 

Silk Fibres (see Fig. 90). — Silk fibres are homogeneous, moderately 
shining; their cut ends are flattened by the blades of the scissors and 
rendered slightly jagged. If from woven goods, the fibres assume wavy 
or spiral impressions. 

Wool Fibres (see Fig. 91). — Wool fibres are coarse, and have saw- 
teeth-like serrations along the edges, corresponding to the edge of the 
imbricated scales covering the cuticle; their structure is faintly striated. 
Hairs of different animals have different forms, and we may observe the 
central medullary canal and a varying amount of pigment. 

Any of these fibres may be found dyed in different colors, which is 
sometimes quite misleading. 

Human Hairs. — Human hairs are also not infrequently found in the 
urine, and may be known by the flat epidermal scales, firmly attached to 



168 



URINARY ANALYSIS AND DIAGNOSIS. 



each other, which form the main mass of the hair, and by the varying 
amount of pigment. 

Feather (see Fig. 92). — Feather may appear in the shape of branch- 




Fig. 90.— Silk Fibres (X 500). 




Fig. 91.— Wool Fibres ( X 500). 

ing formations, which have their origin at the quill, and run in different 
directions or in single barbules. The quill is striated. The barbules are 



EXTRANEOUS MATTERS. 



169 



composed of different sized links, and gradually taper toward the ends, 
which are whip-like. 




Fig. 92. — Feather (X 400). 

Scales from Moth (see Fig. 93). — Scales from the wings of insects, 
such as moths, may also be found. They are more or less delicate, ser- 
rated plates with a stem-like projection, and vary considerably in length 
and breadth. 




Fig. 93. — Scales from Wings of Moth (X 500). 



170 



UBINABY ANALYSIS AND DIAGNOSIS. 



Starch Globules (see Fig. 94). — Starch globules are frequently seen in 
the urine. They are more commonly found in the urine of females, starch 
powders being extensively used for dusting purposes, but individual glob- 
ules from the underwear are also seen. They are oval or round, highly 
refractive, and vary greatly in size, with a more or less central hilum or 
umbilicus, around which are concentric striations. The hilum may be 
either round, oval, or irregular, at times quite large, at times small, and 
occasionally appearing as if split. 

The different varieties of starch, although having the same character- 
istics, vary in shape as well as in size. The three most frequently found 




Fig. 94. — Starch Globules (X 500). 
R, Rice starch; C, corn starch; W, wheat starch. 



in the urine are rice starch, corn starch, and wheat starch. Rice starch 
always appears in the form of oval or oblong, quite regular globules of 
medium size. Corn starch is smaller, irregular, at times almost hexag- 
onal, and contains an irregular hilum. Wheat starch consists of 
large globules, as well as of small, irregular formations, in which latter 
the hilum may be entirely absent or is present only in the form of a 
dot. 

Lycopodium (see Fig. 95). — Lycopodium, somewhat similar to starch, 
and also considerably used for dusting purposes, consists of globular 
formations of different sizes, with a distinct shell, and studded with pe- 



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EX TRA XEO I 'S MA ITERS. 



171 



culiar thorny projections. Many globules seen in urine arc partially 
broken, and in some an irregular or triangular division is noticeable. 




Fig. 95. — Lycopodium Globules (X 500). 

Cellulose (see Fig. 96). — Cellulose occurs in the urine in a variety of 
forms, sometimes in small, sometimes in large masses. It varies consid- 
erably, according to the plant or portion of plant from which it is de- 




mm 

Fig. 96.— Cellulose ( X 500). 



172 



URINARY ANALYSIS AND DIAGNOSIS. 



rived, and may be brown, pale yellow, or practically colorless. It may 
be seen in the urine in the form of a framework, sometimes angular, the 
individual cells being connected with each other by the intercellular sub- 




Fig. 97.— Cork (X 500). 



stance. In the interior of many, though not in all, cells, a nucleus, usu- 
ally somewhat irregular, is present, and both the cells and the nucleus 
are granular. 



r Q^O 




Fig. 98. — Oil-Globules and Air-Bubbles (X 500). 
F, Fat- or oil-globules; A, air-bubbles. 



EXTRANEOUS MATTERS. 



173 



Instead of the irregular angular cells, perfectly regular, either rectan- 
gular or square cells, with large, regular, oblong nuclei, may be seen, and 
these may also be found singly or in masses. 

Cork (see Fig. 97). — A common variety of cellulose seen in urine is 
cork. This occurs either in single cells or smaller conglomerations, and 
has a yellowish-brown or reddish-brown color. The individual cells are 
irregular and greatly vary in size. They are either perfectly homogene- 
ous or contain a small number of indistinct granules. At times many of 
these cells will be found closely packed together. When the cells are thin, 
they may possibly be mistaken for epidermal scales, but their color is 
always sufficient to differentiate them from the latter. 

Oil-Globules and Air-Bubbles (see Fig. 98). — Extraneous fat- or oil- 




Fig. 99. — Flaws in the Glass (X 500). 

globules are of common occurrence in urine. They may be very large 
or extremely small, and are either perfectly round or irregular. They 
are of a high refraction, and can frequently be differentiated by their 
yellowish color. The smallest globules might perhaps be mistaken for 
fat-globules voided with the urine, but are almost invariably associated 
with the larger, more irregular, yellowish globules. 

Air bubbles also vary in size to a great degree, and may be either 
round or irregular; they have a sharply defined, double contour and a 
blue or bluish-black refraction. 

Flaws in Glass (see Fig. 99). — Flaw-s in the glass, as well as scratches 



174 



URINARY ANALYSIS AND DIAGNOSIS. 



in the cover glass, may easily lead to a mistaken diagnosis. The flaws 
are irregular in size and shape, and frequently resemble the wings of i 
butterfly. They have a faint blue refraction and are usually pale. A lit-' 




iriv 



Fig. 100. — Vegetable Matter (X 500). 
Sp, Spiral fibres from air-vessels of plants; V, vegetable fibres; H, hairs of plants; 
C, cellulose; St, starch-globule; Ch, chlorophyl-globule ; F, fat-globules; M, margaric- 
acid needles; So, spores. 

tie care is sufficient to diagnose them; and if their identity is not plain, a 
change of the glass will suffice to note their character. 

Rust particles in both the cover glasses and slides also occur, and' 
are larger or smaller, dark or rust-brown, irregular masses, which 
must not be mistaken for coloring matter in the urine. The smaller 



EXTRANEOUS MATTERS. 



175 



masses somewhat resemble hsematoidin crystals, but are always more 
irregular. 

Vegetable Matter (see Fig. 100). — Vegetable matter of different forms 
may be found in the urine as an admixture from the faeces. Different 




Fig. 101. — Normal Reces (X 500). 
MF, Muscle fibres; CT, connective-tissue shreds; Sp, spiral fibre; C, cellulose; H , 
hair of plant; MS, mucus-thread; MC, mucus-corpuscle; E, epithelia; Ph, triple phos- 
phates; St, starch-globules; D, debris; M, mycelium; S, sarcina; Sa, saccharomyces ; 
F, fat-globules containing margaric-acid needles; BC, bacilli and cocci. 

plants, which remain partially undigested and may be passed with the 
faeces in small masses, will present a variety of features. Spiral fibres 
from the air-vessels of plants are quite numerous in such masses. Hairs 
of plants, as well as vegetable fibres, the latter resembling connective- 



176 URINARY ANALYSIS AND DIAGNOSIS. 

tissue shreds, will be found, besides particles of cellulose. We may fur- 
thermore see starch- and chlorophyl-globules, masses of spores, fat-glob- 
ules, and margaric-acid needles. 

Fceces (see Fig. 101). — Normal faeces may occasionally be found mixed 
with urine, and their constituents must be known. If they are present 
and their accidental admixture can be excluded, the diagnosis of a fistula 
can be made. Although their features vary greatly, depending upon the 
food, the most common with a mixed diet are the following: 

Partly digested muscle fibres of a yellowish or brown color are almost 
constantly seen; in many the striations will be plainly visible, while in 
others no structure can be made out. Connective-tissue shreds from the 
meat diet, in small numbers, are also present. Spiral fibres, hairs of 
plants, and different forms of cellulose are almost constant ingredients, 
as well as starch- and chlorophyl-globules, and fat in the form of globules 
and needles. 

Mucus- threads and mucus-corpuscles are usually found in normal 
faeces, as well as different varieties of epithelia. The latter are mostly of 
the flat variety, derived from the mucous membrane of the anus, although 
a few columnar epithelia are not rare. Crystals of various kinds, but 
most commonly triple phosphates, may be quite abundant. Different 
non-pathogenic bacteria, such as conidia and mycelia in small numbers 
(undoubtedly secondary products), saccharomyces, and large numbers of 
bacilli and cocci, may be found. Besides these features masses of debris, 
digested material, in smaller or larger conglomerations, will be seen. 

The extraneous matters here enumerated as occurring in the urine are 
those which are more commonly found, but other features may be seen at 
one time or another. For instance, water fungi of different varieties, al- 
though rare, are known to occur in urine. It will, however, be a com- 
paratively easy matter 1 to recognize most of the extraneous objects. 



PART THIRD. 

MICROSCOPICAL URINARY DIAGNOSIS. 



PART THIRD. 

MICROSCOPICAL URINARY DIAGNOSIS. 



Although it has been customary, in arriving at a correct diagnosis of 
diseases of the genito-urinary tract, to consider the microscopical exam- 
ination of the urine as only of secondary importance, and, in diagnosing 
the different inflammations of the kidney, to rely solely upon the pres- 
ence of casts, a perusal of the previous pages will show that the micro- 
scope is not only of the utmost importance in all these affections, but is 
frequently the only means of arriving at correct conclusions as to the nat- 
ure of the case. 

It is a well-known fact that in many cases in which a small amount of 
albumin is present in the urine, and in which the clinical symptoms seem 
to point to a nephritis, even if only slight, that diagnosis will not be made, 
because frequent examinations of the urine fail to reveal any tubular 
casts, and the physician is apt to rest satisfied with the diagnosis of 
'•'functional albuminuria"; yet a large number of not infrequently se- 
vere cases of nephritis exist which never show casts in the urine. In cir- 
rhosis of the kidney, for instance, the presence of true casts is quite rare, 
and, when they are present at all, may be so scanty as to be entirely over- 
looked. 

On the other hand, many cases of nephritis, often lasting for years, 
will give such ill-defined clinical symptoms that a kidney inflammation 
is rarely thought of; and the examination of the urine, if made at all, is 
done rapidly and merely with the idea of satisfying one's self that casts 
are not present. Many of these cases will show only a trace of albumin in 
the commencement stage, and might not only be greatly benefited, but 
entirely cured, if a proper diagnosis were made soon enough. Such a 
diagnosis can always be made from a microscopical examination of the 
urine, even without the presence of casts, and the larger number of the 
mild cases never show true casts in the urine at any time. 

The diagnosis of an inflammation or other affection of the kidneys is 
undoubtedly the most important, but a microscopical examination of the 
urine may also be the only means of positively diagnosing the nature of a 
disease of the pelvis Of the kidney, the bladder, and the prostate gland, as 

179 



180 URINARY ANALYSIS AND DIAGNOSIS. 

well as of clearing up a suspected case of inflammation of the seminal ves- 
icles. In the female, an inflammation or ulceration of the vagina, the 
cervix uteri, and the mucosa of the uterus can often be positively identi- 
fied from the examination of urine, without the necessity of an examina- 
tion of the patient. It can thus easily be seen that the microscope plays 
an extremely important role in geni to-urinary affections, either giving the 
first evidence of a disease or helping to clear up a doubtful diagnosis. 

In the following pages only those affections will be considered which 
can be positively diagnosed from a microscopical examination of the urine. I 



I ' 



CHAPTER XVI. 

DISEASES OF THE KIDNEY AND PELVIS. 
I. INFLAMMATIONS OF THE KIDNEY AND PELVIS. 

Classification. — There are probably no diseases in which the opin- 
ions of pathologists differ so much, and in which the nomenclature is so 
varied, as in inflammations of the kidney — nephritis. The result must 
necessarily be confusion. Such different terms as Bright's disease, inter- 
stitial, desquamative, exudative, parenchymatous, and diffuse nephritis 
are met with, and congestion or hyperemia, glomerulitis, pyelo-nephritis, 
and amyloid disease are all looked upon as different affections. While 
some authors use the term Bright's disease as indicating all the different 
varieties of nephritis, others call diffuse nephritis Morbus Brightii; others, 
parenchymatous nephritis; and still others, combinations of different va- 
rieties. 

A uniform classification of nephritis is difficult, since various phases 
of inflammation and degeneration are closely associated and often merge, 
and some authors separate a number of these different phases. One 
classification* is the following: 1. Acute parenchymatous nephritis or 
acute Bright 's disease. Varieties of this form are acute degenerative ne- 
phritis, acute catarrhal or desquamative nephritis, acute glomerulo- 
nephritis, acute diffuse nephritis, to which belongs the hemorrhagic form. 
2. Acute interstitial nephritis, non-suppurative in character, and suppu- 
rative nephritis. 3. Chronic parenchymatous nephritis; to this form be- 
long chronic diffuse and chronic hemorrhagic nephritis, also the large 
white kidney. Its terminal form is known as fatty contracting kidney or 
secondary interstitial nephritis. 4. Chronic interstitial nephritis, divided 
into primary chronic interstitial or red granular kidney or arteriosclerotic 
nephritis or gouty nephritis, and secondary chronic interstitial, the ter- 
minal form of chronic parenchymatous nephritis. 

Delafield and Pruddenf mention three principal varieties of inflam- 
matory processes of the kidney: 1. Acute suppurative nephritis. 2. 
Acute diffuse nephritis. 3. Chronic diffuse nephritis. The variations in 

* Stengel, "Textbook of Pathology," 4th Edition, 1903. 

f "Handbook of Pathological Anatomy and Histology," 7th Edition, 1904. 

181 



182 URINARY ANALYSIS AND DIAGNOSIS. 

type in acute diffuse nephritis are the following : (a) Glomerulo-nephritis ; 
(b) parenchymatous or degenerative type ; (c) hemorrhagic type ; (d) ex- 
udative type; (e) productive type or interstitial type. Variations in type 
in chronic diffuse nephritis are: (a) Parenchymatous or degenerative 
type; and (b) interstitial type. 

Ziegler* speaks of acute, subacute, and chronic Morbus Brightii. He 
considers the degenerative and inflammatory changes together as hsema- 
togenous nephritis, and divides nephritis into (1) acute, subacute, and 
chronic hematogenous parenchymatous nephritis, the latter leading to 
induration and atrophy, and (2) into suppurative nephritis. 

It is unnecessary to go any further into the different classifications, 
which no two authors give alike, but it may be mentioned that some pre- 
fer to speak primarily of an acute and a chronic nephritis only, dividing 
them into parenchymatous and interstitial secondarily. 

It is, therefore, not at all surprising that the pathology of nephritis is 
considered to be one of the most complicated chapters in pathology ; yet 
it will become perfectly plain, and the features found in urine easily ex- 
plained, if we consider the anatomical structure of the kidney, which is 
that of a compound tubular gland, consisting of epithelial and connective 
tissue; the latter alone carries the blood-vessels, the contents of which, 
the blood, furnish the material from which the epithelia produce the 
secretions. 

Experiments have frequently been made to show that pathological 
conditions of the epithelia can exist independently of the underlying con- 
nective tissue carrying the blood-vessels. It has been asserted that in 
acute cases of poisoning, such as with cantharides and phosphorus, the 
pathological process is confined to the kidney epithelia alone. Other ex- 
periments have, however, conclusively proved that an independent path- 
ological condition of the epithelia does not exist. The poison, before it 
reaches the epithelia, must pass the walls of the blood-vessels and the . 
connective tissue lying between the epithelia and the walls of the blood- 
vessels, and has an irritating influence upon the latter. In this connec- 
tive tissue, changes are always found, though they may be confined to 
serous transudation, sufficient to show that the epithelium cannot be- 
come diseased primarily and independently of the surrounding connective 
tissue. 

It is, therefore, evident that the classification by Virchow, of inflam- 
mations into interstitial, that is, confined to the connective tissue, and 
parenchymatous, confined to the epithelia, is not strictly correct. Every 
inflammation is primarily an interstitial one, and every parenchymatous 

* "Lehrbuch der speciellen pathologischen Anatomie," 10. Auflage, 1902. 



DISEASES OF THE KID WET AND PELVIS. 183 

inflammation must also at the same time be an interstitial one. It is per- 
fectly true, however, that the pathological changes may be more pro- 
nounced in the epithelia than in the connective tissue; the latter may 
not pass beyond the stage of serous transudation, while in the former 
coarse granulation, so-called cloudy swelling, may occur. In cases of 
phosphorus poisoning fatty degeneration may be present. 

The character of an inflammation depends to a great degree upon the 
nature of its exudate, which may be either serous, fibrinous, or albumin- 
ous. In former years inflammations of mucous membranes were divided 
into catarrhal and croupous; in the first a serous or sero-mucous exudate 
is formed, while in the second it is fibrinous in its character. These 
names, though not of great significance, are perhaps preferable to Vir- 
chow's terms — interstitial, desquamative, and parenchymatous — which, 
as has been shown, cannot be carried out. An inflammation in an organ 
composed of connective and epithelial tissue will affect all its component 
parts to a greater or less degree, so that it will be diffuse to a certain ex- 
tent at the outset. The difference exists only in the degree in which the 
different tissues are affected. We may, if we wish, speak of an interstitial 
inflammation when the pathological changes are more pronounced in the 
connective tissue, and of a parenchymatous inflammation when they are 
more pronounced in the epithelia. 

As every inflammation of the kidney is bound to be more or less dif- 
fuse in its character — by which term is not meant that it affects the en- 
tire organ uniformly, but simply all the component parts of the organ at 
the seat of inflammation — and the term Bright's disease conveys no 
meaning as to the character of the inflammation, which may run an 
acute, subacute, or chronic course, all cases of nephritis may best be 
divided in the following manner: 

1. Catarrhal, interstitial, or desquamative nephritis. 

(a) Acute. 

(b) Subacute. 

(c) Chronic, terminating in cirrhosis of the kidney. 

2. Croupous or parenchymatous nephritis. 

(a) Acute. 

(b) Subacute. 

(c) Chronic, terminating in atrophy of the kidney. 

3. Suppurative nephritis. 

(a) Acute. 

(6) Chronic. 
When the greater part or the entire kidney is transformed into a puru- 
lent cavity, the term pyonephrosis is applied. 

Congestion or hyperemia of the kidney cannot be considered as a sep- 



184 URINARY ANALYSIS AND DIAGNOSIS. 

arate affection, since it is either the first stage of a commencing inflam- 
mation or a mere irritation, which cannot be properly termed inflamma- 
tory as yet, but which sooner or later will undoubtedly develop into an 
inflammation. 

Glomerulitis or glomerulo-nephritis is not an independent inflamma- 
tory process, but only a symptom of one of the inflammations, since the 
glomeruli are always attacked to a greater or less degree in every nephritis. 

Fatty and waxy, or amyloid, degenerations of the kidney are always 
secondary products, due to a chronic inflammation, and part of such an 
inflammation. 

Pathological Changes. — Let us now briefly consider the pathological 
changes which take place in these different inflammations of the 
kidney : 

1, Catarrhal Inflammation. — In catarrhal or interstitial inflammation 
of a mild character, an cedematous swelling of the connective tissue is 
present, with swelling and granular cloudiness of the epithelial covering 
and subsequent desquamation of the epithelium. The blood-vessels show 
a more or less complete distention with blood-corpuscles, without appar- 
ent alteration in the structure of their walls. The cedematous swelling of 
the connective tissue, as well as the desquamation of the epithelia, is due 
to a serous exudation from the blood-vessels. On account of this serous 
exudation, the epithelia may become partly changed to mucus. 

In severer cases an inflammatory infiltration of the connective tissue, 
which leads to hypertrophy, takes place, with proliferation, desquama- 
tion, and, finally, hyperplasia of the epithelium. In the highest degree of 
catarrhal inflammation, all the constituent parts of the kidney tissue have 
disappeared in the inflammatory infiltration. 

At the very commencement of an inflammation, the production of 
pus-corpuscles takes place, partly from the emigration of white blood- 
corpuscles, partly from the interstitial connective tissue and partly from 
the epithelium, which latter undoubtedly enters into the formation of 
pus-corpuscles to a great degree by division and endogenous cell-prolif- 
eration, as had already been shown by George Johnson, in the year 
1852. As long as the newly formed corpuscles remain in connection with 
the tissue, we have inflammatory corpuscles; but as soon as they are 
torn from their connection with the tissue and appear in the urine, the 
term pus-corpuscles must properly be applied to them. 

When the disease has become chronic, the surface of the kidney is 
marked by irregular, shallow depressions, or by granulations, the capsule 
being adherent in most cases. The irregular depressions are due to re- 
tractions of newly formed connective tissue, which is formed at the ex- 
pense of the uriniferous tubules. Chronic catarrhal or interstitial nephri- 



■ 



DISEASES OF THE KIDNEY AND PELVIS. 185 

tis invariably leads to a shrinkage — cirrhosis — of the kidney. The whole 
kidney is considerably reduced in size, and the irregularities on the surface 
are well marked. Both the cortical and medullary substances are much 
narrower than in the normal condition ; this being more particularly the 
case in the cortex, of which, in advanced stages, only slight remnants are 
left, corresponding with the elevations of the surface. There is a partial 
destruction of tufts or glomeruli, tubules, and blood-vessels. The newly 
formed connective tissue is more or less regularly distributed throughout 
the kidney structure, the uriniferqus tubules being in part transformed 
into connective tissue, while still retaining the outlines of their original 
configuration. 

The obliteration of a number of the narrow tubules, including the 
ascending and descending branches, explains the clinical fact that per- 
sons affected with cirrhosis of the kidney void large quantities of urine 
almost destitute of salts. It is well known that from the glomerulus only 
a watery liquid, containing few salts, is voided, which becomes thicker by 
the addition of the saline constituents excreted by the narrow tubules. 
It is in the narrow tubules that much of the watery part of the urine is 
restored to the thickened blood running in the neighboring capillaries. 
If the function of the tubules be much interfered with, the interchange 
between the liquid contents of the tubule and the solid constituents of the 
blood will not take place, and consequently the urine will be voided in 
about the same condition in which it was pressed into the capsule from 
the tuft. Numbers of the convoluted tubules perish also through the in- 
creased formation of connective tissue, while from others the epithelia are 
simply desquamated and appear in the urine. 

2. Croupous Inflammation. — In croupous or parenchymatous inflam- 
mations the surface becomes partially or completely denuded of its epi- 
thelium, a coagulated albuminous or fibrinous exudate is formed upon 
the surface, there is considerable hyperemia of the blood-vessels, as well 
as a pronounced swelling and inflammatory infiltration of the connective 
tissue. E. Wagner has shown that the epithelia enter very actively in 
the formation of the so-called croup membrane, and their protoplasm 
becomes almost completely destroyed in the fibrinous exudate. 

In this variety of inflammation the emigration of colorless blood-cor- 
puscles is quite pronounced. Epithelia alone cannot produce a croup 
membrane, but require the presence of an exudate from the blood, and 
the essential constituent of the croup membrane is the coagulable albu- 
jsule minoid body from the blood. We now have the formation of casts ; the 
j re- ppithelia lining the tubules become saturated with the albuminous exu- 
e v. date, swell, grow pale, and finally, by coalescence of the epithelia thus 
plui- degenerated, produce the mass called a tubular cast. 



of 



on- 



^ 



186 URINARY ANALYSIS AND DIAGNOSIS. 

In chronic croupous nephritis the kidney has an entirely different ap- 
pearance from that found in chronic catarrhal nephritis and cirrhosis of 
the kidney. It is more frequently enlarged than diminished in size. The 
surface is often nodulated, and between the nodules are seen deep cica- 
tricial retractions. These retractions are never found uniformly over the 
surface, and the capsule is adherent to the retractions. The cortical sub- 
stance is absent in those parts corresponding with the retractions of the 
surface, while in other places the cortex may be unaltered or even in- 
creased in bulk. The pyramidal substance may be unchanged or may be 
diminished. In contradistinction to the more or less uniform shrinkage 
of the kidney, to which the name cirrhotic is given, the partial destruction 
of the tissue which occurs in chronic croupous nephritis may be termed 
atrophy, since in the most diseased portions only traces of the original | 
kidney structure will be found. 

In the depressed cicatricial portions of the cortical substance a large 
amount of connective tissue, only scantily supplied with blood-vessels, is 
found. There is no regularity in the arrangement of the connective tis- 
sue, and only remnants of the former tubules are found, together with ir- 
regularly scattered sections of tubules, from which the epithelial lining 
has entirely disappeared. In the most pronounced cases, in addition to 
the atrophied portions, the large amount of newly formed connective tis- 
sue present in different places constitutes a regular hypertrophy. 

Both fatty and waxy degeneration may be present in cirrhotic as well 
as in atrophied kidneys, but these changes are much more pronounced in 
the latter than in the former. In the so-called large white kidney, the 
highest degree of fatty degeneration occurs as a secondary result of 
chronic croupous nephritis. Cystic degeneration may also be present in 
these cases, and is more pronounced in chronic croupous nephritis. 

3. Suppurative Inflammation. — The most intense variety of inflamma- -ffoi 
tion of the kidney is the suppurative, which is similar to the formation of 
an abscess in other organs. For a long time this variety was considered 
to be a purely interstitial inflammation, since the opinion prevailed that 1 B 
pus-corpuscles could be formed only from connective-tissue cells. There 
is, however, no doubt, as previously stated, that the epithelia take an ac- 
tive part in the formation of pus. The blood-vessels soon become de- 
stroyed in this variety. Pus is disintegrated tissue, and in its formation 
all the elements of the tissue take part. 

There may be either a number of small disseminated foci of suppura- 
tion or a large abscess, usually, if not invariably, caused by an invasion 
of pyogenic cocci. Besides the abscess, the kidney may present the feat- 
ures either of a catarrhal or of a croupous inflammation. When the ab- 
scesses become chronic, a dense connective-tissue capsule, the pyogenous 



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sfcdj 
Ni«e 
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'The 

•Clitic 

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THIRD EDITION. 

iANUAL, OF THE 

DISEASES OF 
THE EYE j& 

For Students and General Practitioners. 
By CHARLES H. MAY, M.D. 

lief of Clinic and Instructor in Ophthalmology, 
Eye Department, College of Physicians and 
* Surgeons, Medical Department. Colum- 
bia University, New York. 

424 Pages, 12mo, with. 275 Original 
Illustrations, including 36 Colored 
Figures on 16 full page plates. 
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The great difficulty in preparing a book of 
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ith this idea in view, the author has made 
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The illustrations, except of those showing 
struments, are original, and have been in- 
led wherever it seemed that they would be 
I' value in elucidating the text. Those in 
dors represent the most common ophthal- 
pscopic conditions, a knowledge of which 
i desirable in the treatment of general and 
trvous diseases as well as in ocular diagnosis. 



PRESS NOTICES 

1 It is quite safe to say that the author has suc- 
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cicise and practical manuals of diseases of the eye 
fit we now possess ; in fact, the only one that gives 
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Philadelphia Med. Jour. 
j The work is admirably adapted for undergradu- 
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DISEASES OF THE KIDNEY AND PELVIS. 187 

membrane, may occasionally be found, and the pus becomes inspissated 
into a cheesy mass. 

With these remarks upon the pathology of the different varieties of 
nephritis, we are ready to understand the features found in the urine of 
these cases. Although it is not possible to diagnose an acute, subacute, 
or chronic inflammation from the urine alone, in all cases of nephritis, it 
can undoubtedly be done from the different features seen in most cases, 
especially the more pronounced. 



CONGESTION OR HYPEREMIA OF THE KIDNEY. 

From what has been said before, it is evident that the diagnosis of an 
inflammation can be made as soon as pus-corpuscles are found in the 
urine: without these, no such diagnosis is possible. In some cases, in 
which a trace of albumin is present, or no albumin whatever is found, an 
extremely small number of pus-corpuscles, perhaps one or two in every 
field of the microscope, is seen, together with the same number of epithe- 
lia from the convoluted tubules of the kidney, and a few red blood-cor- 
puscles. These features, wmen present in such very small numbers, are 
not sufficient for the diagnosis of an inflammation, though the urine can- 
not be called normal. In such cases the diagnosis of a congestion or hyper- 
emia of the kidney is possible, and in them we do not expect to find true 
^asts. As soon as true casts are present, even if the features are very 
»canty, a distinction between severe congestion and inflammation is prac- 
ically impossible in most cases. 

In some, though not in all, cases of congestion, an increase of mucus, 
n the form of both strings and corpuscles, is noticeable; and here cylin- 
Iroids, which can sometimes hardly be distinguished from hyaline casts, 
nay be present in small or moderate numbers. When these features are 
bund, caution is necessary, since such an increase of mucus is often seen 
is a pre-stage of an inflammation, especially in acute eruptive and in- 
lammatory diseases, such as scarlet fever, diphtheria, and pneumonia. 

Causes. — Congestion of the kidney is of common occurrence, but is 
requently overlooked. It may be present accompanying almost any dis- 
ase, and may be produced by different medicinal agents, such as cu- 
>ebs, copaiba, turpentine, cantharides, and mineral acids. Occasionally it 
eems as if simple exposure to cold and moisture is sufficient to produce 
t. In cases of catarrhal or gonorrhceal urethritis, especially if accom- 
panied by slight prostatitis, an irritation of the kidney is often found, 
jving the features enumerated above. The presence of an increased 



188 URINARY ANALYSIS AND DIAGNOSIS. 

amount of salts, such as uric acid or calcium oxalate, will not infrequently 
be responsible for the condition. 

If the cause which has produced the congestion be quickly removed, 
the affection may disappear at once; but if not, an inflammation will 
sooner or later result. 

If the congestion is pronounced, a more or less severe hemorrhage from 
the kidney may take place, even without an inflammation. In such cases 
red blood-corpuscles will be numerous, epithelia from the convoluted tu- 
bules may be somewhat more abundant, and, in addition, scanty, delicate 
shreds of connective tissue will appear in the urine. All the features may 
have a yellowish hue from the coloring matter of the blood. 



CATARRHAL OR INTERSTITIAL NEPHRITIS. 



a 

r 

Catarrhal, interstitial, or desquamative nephritis frequently runs a bl 
comparatively mild course, being, as a rule, the mildest of the three vari- p 
eties of inflammation. Severe acute cases, which may cause the death F 
of the patient, do, however, occur. Catarrhal nephritis is a much more Wl 
common affection than is generally supposed, and may exist for many p 
years without giving any pronounced clinical symptoms. It is by no 
means rare that a urine which is examined microscopically with a view of 
detecting other affections will show the presence of such an inflammation 
before the clinical symptoms are clear, though the patient may have suf- 
fered for a long time from occasional headaches and general depression. 

Causes. — Catarrhal nephritis often exists in a mild degree without any P 1 
known cause. Exposure to cold and moisture seems to be a frequent 
cause, as are also different medicinal agents, such as arsenic, iodine, phos- 
phorus, mercury, turpentine, and cantharides. In lead-poisoning the dis- 
ease is often present. It is not infrequently found in persons of sedative 
habits and in those with a so-called gouty or rheumatic diathesis. That 
persons suffering from gout and rheumatism usually void a large amount 
of uric acid is well known ; but there are others who continually void uric 
acid and calcium oxalate in excess without giving any rheumatic symp- 
toms. In these cases — lithsemia and oxaluria — catarrhal nephritis fre- 
quency occurs, and it seems that the excess of the salts, or the concentra- 
tion of the urine itself, has an irritating tendency upon the kidney tissue. 
The continued use of alcohol is an important factor in the production of 
the disease. 

In acute contagious diseases croupous nephritis is of more common 
occurrence than catarrhal, but the latter, contrary to the general belief, 
undoubtedly occurs. If the urine is carefully examined in these diseases, 



DISEASES OF THE KIDNEY AND PELVIS. 189 

a small amount of albumin, perhaps not more than a trace, may be found 
in the milder cases, and upon microscopical examination the features of 
a catarrhal inflammation are seen. Even in some fatal cases, an exam- 
ination of the kidney may reveal a catarrhal and not a croupous inflam- 
mation. In pregnancy, also, catarrhal nephritis occurs, and is not at all 
rare. 

As a secondary affection, this variety of inflammation may be present 
in many acute and chronic fatal diseases, so much so that, upon post- 
mortem examinations, absolutely healthy kidneys are usually found only 
after death by accident. 

Finally, catarrhal nephritis is common as a result of various genito- 
urinary affections, as, for instance, in some cases of gonorrhoea, when first 
a prostatitis, then, in succession, a cystitis, pyelitis, and nephritis will de- 
velop. In syphilitic and tubercular affections it is frequently seen. 

Clinical Symptoms. — The clinical symptoms of the disease vary greatly, 
but in the milder cases are anaemia, occipital headache, pain in the lumbar 
region, loss of appetite, sleeplessness, and general depression. In cirrhosis 
of the kidney the symptoms are pronounced, loss of flesh and strength is 
well marked, vomiting may be frequent, there may be dyspnoea, and the 
pulse is tense, hard, and often full. The acute cases may occur at any age, 
but the chronic cases are mostly found in persons more advanced in years, 
especially after the age of forty years. 

Features Found in Urine. — Albumin, although present in most of the 
?ases, may be found in very small amount only, and in some it seems to 
oe entirely absent. A large amount of albumin is rare in catarrhal ne- 
Dhritis, and is seen only in the severe cases. In many, a trace of albumin 
mly will be found, and unless a careful observation is made, it may escape 
ietection entirely. The question whether a pronounced inflammation of 
;he kidney may exist with entire absence of albumin is still an open one. 
Many authors claim that it does occur, but many times when albumin is 
;aid to be absent careful examination will show a trace. It is undoubt- 
edly a fact that in catarrhal nephritis albumin may be absent at certain 
imes, but frequent examination will almost invariably show at least a 
race in every case. 

The specific gravity, amount, and appearance of the urine will vary 
greatly. In milder cases these may be perfectly normal. In acute ca- 
arrhal nephritis the specific gravity is, as a rule, somewhat higher than 
lormal, the amount slightly decreased, and the color darker. The amount 
»f urea is usually increased, and salts may be present in rather large num- 
bers. In chronic cases the amount of urine is invariably increased, some- 
imes to a great degree; the specific gravity is low and the color pale, 
n such cases the specific gravity is not infrequently below 1.012 or 1.010 



190 URINARY ANALYSIS AND DIAGNOSIS. 

continually, the amount of urea and salts being diminished. The sedi- 
ment found in the urine varies, but is usually small, and may at times 
be no more abundant than in normal urine. 

A positive diagnosis of catarrhal or interstitial nephritis is in many 
eases possible only by a microscopical examination of the urinary sedi- 
ment. This will vary in acute, subacute, and chronic cases. The diagno- 
sis of a nephritis can be made when pus-corpuscles and epithelia from the 
convoluted and narrow tubules of the kidney are present in the urine. 
Columnar epithelia from the straight collecting tubules are of rarer oc- 
currence, and indicate an invasion of the pyramidal substance. 

Before the presence of epithelia from the convoluted tubules of the 
kidney can be diagnosed, pus-corpuscles must be found and taken as a j 
standard, since the latter vary in size to a certain degree in every given 
case. Kidney epithelia from the convoluted tubules are about one-third - 
larger than the pus-corpuscles. These epithelia are never found in nor- 
mal urine, and to render their diagnosis positive, they should always be 
compared with pus- or white blood-corpuscles. A single kidney epithe- 
Hum is of no value for the diagnosis, and a small number, at least, should 
always be found, in order to render the diagnosis positive, since, as is well 
known, pus-corpuscles vary in size to a small degree even in the same case, j 
This difference is, however, small, and never so pronounced as to render 
the diagnosis between pus-corpuscles and kidney epithelia difficult. The 
difference in size between the two can alone determine the nature of the 
epithelia, since the presence or absence of a nucleus has no significance 
whatever. A nucleus maybe seen in pus-corpuscles, as well as in epithe- 
lia, though it is found more frequently in the latter than in the former. 
In finely granular pus-corpuscles a nucleus will always be visible, while 
in coarsely granular epithelia it may not be seen. 

Kidney epithelia from the convoluted as well as those from the narrow 
tubules generally have a round shape in urine, though angular or irregu- 
lar forms are also seen. When the urine is still warm at the time of ex- 
amination, or in a warm temperature, the pus corpuscles may not infre-: 
quently show amoeboid movement and assume a variety of different 1 
shapes, while the kidney epithelia, as a rule, retain their round or slightly -■ 
irregular form.* 

In this variety of nephritis casts are usually absent ; if they are pres- 
ent at all, they are found in extremely small numbers, and then we almost 

* Attention should here again be called to the fact that low magnifying powers 
of 100 or 150 diameters are absolutely useless for a diagnosis of kidney epithelia. 
A magnifying power of at least 400 diameters must be used, and with such a 
power the difference between pus-corpuscles and kidney epithelia becomes appar- 
ent at once. 




;g. 102. — Acute Catarrhal Pyelonephritis (Acute Interstitial Nephritis) 

and Cystitis (X 500). 
RB, Red blood-corpuscles ; PC, pus-corpuscles ; CE, epithelia from the convoluted tubules 
the kidney; UE, epithelia from the ureter; PE, epithelia from the pelvis of the kidney; 
B, epithelia from the upper layers of the bladder; MB, epithelium from the middle 
yers of the bladder; UA, uric acid; UG, uric-acid gravel; US, sodium urate; OC, 
lcium oxalate. 



DISEASES OF THE KIDNEY AND PELVIS. 193 

nvariably see small hyaline casts from the narrow tubules only. The 
iiagnosis, however, hinges upon the presence of epithelia from the con- 
voluted and narrow tubules and pus corpuscles, together with other feat- 
ires to be presently mentioned. 

Acute Catarrhal or Interstitial Nephritis (Fig. 102). — In an acute 
•atarrhal nephritis the pus-corpuscles and cuboidal epithelia from the 
involuted tubules of the kidney are present in at least moderate but 
isually large numbers; the more numerous these features, the severer is 
he nephritis. Besides these, we usually find red blood-corpuscles in mod- 
rate or fairly large numbers, though they are not sufficiently numerous 
o admit of the diagnosis of a hemorrhage. Moderate numbers of red 
lood-corpuscles always indicate an acute inflammation. 

These three features are perfectly sufficient for the diagnosis, but are 
arely found alone. In many cases different salts, such as calcium oxa- 
ite, uric acid, and sodium urate, are found in small amount. In the se- 
erer cases a few columnar epithelia from the straight collecting tubules 
re also present. As a general rule, an inflammation of the pelvis of the 
idney is associated with the nephritis, though this may be absent, 
^hen present, the irregular, lenticular, pear-shaped, or angular epithelia 
•om the pelvis are also seen in varying numbers, and the diagnosis of a 
yelo-nephritis can be made. Such a diagnosis does not by any means 
iggest an abscess of the kidney, as is frequently supposed, but simply 
le extension of the inflammatory process to the pelvis of the kidney, 
esides these, epithelia from the ureters in small numbers, which are 
Dout twice the diameter of pus-corpuscles, and therefore larger than the 
idney epithelia, are rarely absent. 

If the nephritis is at all pronounced, symptoms of an accompanying 
ostitis are also seen, and we will then find larger cuboidal epithelia from 
le middle layers of the bladder — which in urine appear round or oval in 
ost cases — as well as flat epithelia from the upper layers with the other 
atures. 

The severer the acute inflammation the more abundant are the ac- 
>mpanying features of pyelitis and cystitis. In such severe cases hya- 
le casts from the narrow tubules are occasionally present; if these are 
en in small numbers only, the diagnosis does not necessarily become 
langed. The latter feature is comparatively rare, and in most cases 
-sts of any kind are entirely absent. 

Chronic Catarrhal or Interstitial Nephritis (Fig. 103). — As soon as 
e inflammation has become chronic, the features in the urine are differ- 
tt. Red blood-corpuscles are now either entirely absent, or, when pres- 
Lt, are found in small numbers only. We observe, however, a varying 
mber of small, gfistening, highly refractive globules and granules, partly 
13 



194 URINARY ANALYSIS AND DIAGNOSIS. 

lying free, partly in the pus-corpuscles and epithelia. These are fat-glol 
ules and -granules, and the more numerous they are the more chronic I 
the inflammation. They are found in larger or smaller groups scattere 
throughout the field, and are seen in varying numbers in the pus-corpus 
cles and epithelia. In milder cases only two or three may be present i 
some epithelia, while they are absent in others; but in the old, chroni 
cases almost every epithelium will be seen filled with the glistening glol: 
ules. When very numerous, they not only denote chronicity, but also i 
commencing fatty degeneration of the kidney, which, in this variety c 
nephritis, is never pronounced. Fat-globules are not seen in acute cases; 

The features found in a chronic catarrhal nephritis are, therefore, th ] 
following: Pus-corpuscles, some containing fat-globules and -granules; cu 
boidal epithelia from the convoluted tubules of the kidney, a few, or th j 
larger number, containing fat-globules; free fat-globules in differed 
groups; in the severer cases, also, columnar epithelia from the straigb 
collecting tubules, usually in small numbers only. Irregular or rouH 
epithelia from the pelvis of the kidney, cuboidal (round) epithelia fror 
the ureters, and still larger cuboidal epithelia from the middle layers c 
the bladder, either with or without fat-globules, may be present in sma 
or moderate numbers. 

Another feature of chronicity which may occasionally be found i 
haematoidin, in the form of rust-brown needles and plates. These ma 
either lie free or when of small size may be seen in the pus-corpuscles an 
epithelia. They denote a previously existing hemorrhage, and show tha 
the pathological process cannot be an acute one. 

Red blood-corpuscles, as previously mentioned, are either entirely at 
sent in a strictly chronic case, or, when present, are found in small num 
bers only. Not infrequently, however, all the features of a chronic i|ij 
flammation are seen, and yet blood-corpuscles are fairly numerous. Th i 
invariably denotes a fresh acute outbreak engrafted upon the chroni 
process. Such acute attacks are not rare in cases of long standing, an 
may be produced by the slightest cause, such as exposure to cold, d< 
rangements of digestion, etc. Again, the chronic inflammation may t 
confined to one kidney and an acute process affect the second kidney. 

In Subacute Catarrhal Inflammations some features of both the acut 
and the chronic form will be found. We have a small or moderate nun 
ber of red blood-corpuscles and a small number of fat-globules, the latt< 
being rarely seen in groups, but only in a few pus-corpuscles and epitheli; 
and there may be only one, two, or three in them. The other features n : 
main the same. 

When the features as here described are present, it will not be difficu 
to tell whether an inflammation is acute, subacute, or chronic; but son 



ii 



I 







UE 

os 

r 

em _ 

Fig. 103. — Chronic Catarrhal Pyelonephritis (Chronic Interstitial Nephritis) 

and Cystitis (X 500). 
PC, Pus- corpuscles containing fat-globules; CE, epithelia from the convoluted tubules 
of the kidney containing fat-globules ; SE, epithelium from the straight collecting tubules 
of the kidney containing fat-globules; UE, epithelia from the ureter containing fat- 
globules; PE, epithelia from the pelvis of the kidney; MB, epithelia from the middle 
layers of the bladder; FG, free fat-globules; RB, individual red blood-globule. 



DISEASES OF THE KIDNEY AND PELVIS. 197 

cases may at times be seen where neither red blood-corpuscles nor fat- 
globules can be discovered, and then the diagnosis of a simple catarrhal 
or interstitial nephritis can alone be made. These cases are usually of a 
mild character. 

Besides all these features, the appearance of the pus-corpuscles, as 
noted in a previous chapter, must be taken into consideration, and may 
help to clear up the case where the clinical features and the history are 
vague. As long as the constitution of the patient is still fairly good, 
which can easily be determined by the number of coarsely and finely 
granular pus-corpuscles present in the case, we may feel confident that 
the nephritis cannot have lasted any length of time nor be a severe one. 

Cirrhosis of the Kidney (Fig. 104). — The outcome of chronic ca- 
tarrhal nephritis is always a shrinkage — cirrhosis — of the kidney, the so- 
called hob-nail kidney. The features of this, as seen in the urine, are so 
characteristic that a positive diagnosis can always be made. They are 
the following: 

1. A large amount of urine, being occasionally increased to double the 
normal quantity or more, and the color being pale. 

2. A continuously low specific gravity, usually below 1.012 or 1.010, 
or even not more than 1.006 at any time. 

3. The presence of a small amount or perhaps not more than a trace 
of albumin. 

4. A diminution of all salts. 

5. Pus-corpuscles, present in small numbers, some containing fatr- 
globules. 

6. Epithelia from the convoluted and straight collecting tubules of 
the kidney, in small numbers, some or even all containing fat-globules. 

7. Free fat-globules and -granules. 

8. Connective-tissue shreds, of small sizes and in small numbers only. 

9. Broken-down constitution, as seen by the pale, finely granular pus- 
corpuscles, in which not infrequently one or more nuclei become plainly 
visible. 

Epithelia from the pelvis of the kidney, the ureter, and the middle 
layers of the bladder may also be present. 

As previously explained, urine from a badly diseased kidney contains 
few salts. In some cases, in which all the other features of a cirrhosis are 
present, a large amount of salts, such as uric acid or phosphates, is also 
seen, the specific gravity being 1.014 or higher. The conclusion which 
can then be reached is that only one kidney has so far become affected, 
the salts being voided by the other kidney. The prognosis will, in such 
cases, be better than when salts are not seen under the microscope. 

Catarrhal Pyelitis. — A few words should here be » said about ca- 



198 URINARY ANALYSIS AND DIAGNOSIS. 

tarrhal pyelitis, which is occasionally a primary, independent affection 
It has been claimed that the term " catarrhal " for an inflammation of thl 
pelvis of the kidney is incorrect. As these inflammations, however, have 
undoubtedly the character of catarrhal processes,* we can speak of ca- 
tarrhal pyelitis, just as of catarrhal nephritis. 

When pyelitis occurs as such, it is easily diagnosed from the urine, th( 
features being the same as in catarrhal nephritis, except that pelvic epi- 
thelia instead of kidney epithelia are found. Being in many cases due tc 
an abundance of salts, these will usually be present in such cases. As a 
rule, pyelitis is an accompanying element of a nephritis, giving us a ca- 
tarrhal pyelo-nephritis, with the features as above described. 

Ureteritis. — A primary, independent inflammation of the ureter is 
rare, a ureteritis being almost invariably secondary to a pyelitis or a cys- 
titis. It may be caused by infections of any kind or may be due to im- 
pacted calculi. In a catarrhal inflammation the same features as those 
seen in nephritis and pyelitis are seen, except that epithelia from the ure- 
ter alone are found. Ulceration and suppuration may also occur, giving 
features similar to those seen in ulcerative and suppurative conditions to 
be described in other organs. In the latter processes, however, columnar 
epithelia are present. In injury to the ureter due to the ureteral catheter, 
red blood-corpuscles, small cuboidal and columnar epithelia, and connec- 
tive-tissue shreds are seen in the urine. 



CROUPOUS OR PARENCHYMATOUS NEPHRITIS. 

Croupous nephritis is usually a severer affection than the catarrhal, 
and is not quite as frequent as the latter. When present, its symptoms^ 
are always more or less pronounced, and only in rare cases will it exist for 
some time without giving symptoms sufficiently characteristic to suspect 
a nephritis. 

Causes. — Its causes are numerous, being partly the same as those 
found in the catarrhal variety. Exposure to cold and moisture is a com- 
mon cause, and it is not infrequently the consequence of irritant poisons 
acting upon the system, such as turpentine, bichloride of mercmy, can- 
tharides, arsenic, large doses of iodide of potash, and occasionally even 
chlorate of potash. As in catarrhal nephritis, it may be found in persons 
of a sedative habit and in those suffering from a lithaemia. The continued 
use of alcohol is an important causative factor. 

Among the most common causes in the production of the disease are 

* Ziegler, " Lehrbuch der speciellen pathologischen Anatomie," 10. Auflage, 
1902. 




Fig. 104. — Cirrhosis of the Kidney, with Chronic Catarrhal 
Cystitis (X 500). 
PC, Pus-corpuscles ; CE, epithelia from the convoluted tubules of the kidney, contain- 
ing fat-globules ; SE, epithelium from the straight collecting tubules of the kidney ; UE, 
epithelium from the ureters; PE, epithelium from the pelvis of the kidney; MB, epithe- 
lium from the middle layers of the bladder; CT, connective- tissue shreds; FG, free fat- 
globules; MT, mucus-strings. 



DISEASES OF THE KIDNEY AND PELVIS. 201 

the acute eruptive and inflammatory diseases, especially scarlatina, diph- 
theria, and pneumonia; less frequently typhoid fever and smallpox. It 
is occasionally seen during pregnancy, though it is not always easy to ac- 
count for its occurrence. Pressure produced by the gravid uterus may be 
partly responsible for it. In chronic affections, such as heart diseases, tu- 
berculosis, and syphilis, it may also be seen, as well as in rarer cases of 
malarial poisoning. 

As a result of strictures of the urethra, prostatitis, and hypertrophy 
of the prostate gland, croupous nephritis is occasionally seen. The orig- 
inal inflammation is the cause of a cystitis, and, from the bladder, it as- 
cends to the ureters, pelves, and kidneys, ending in a croupous nephritis. 
A peculiar occurrence is its appearance in strong, healthy athletes during 
active training, especially when they subsist upon a meat diet ; the same 
may be the case in fat people who desire to reduce their weight quickly 
by an exclusively meat diet. 

Clinical Symptoms. — The clinical symptoms vary with the intensity of 
the process, though anaemia, headache, loss of appetite, emaciation, nau- 
sea, and loss of strength are all generally present. Severe acute cases 
may be ushered in by chills, followed by a rise in temperature. Very 
soon oedema will appear, first being localized, especially on the eyelids, 
but soon becoming general, involving the face, hands, feet, and cellular 
tissues generally. To these symptoms will be added dull, aching pains in 
the lumbar region, and, in the severe cases, uraemic symptoms. 

Features Found in Urine.— Albumin is almost invariably present in 
comparatively large amount, and in some cases may be extremely abun- 
dant, reaching one-half of one per cent or even more. It is claimed that 
occasionally croupous nephritis may exist without the presence of any al- 
bumin ; that albumin may exceptionally occur in small quantities only is 
undoubted, but it is probably never absent altogether, as careful tests 
for albumin will show. 

In acute croupous nephritis the amount of urine is usually decreased, 
sometimes to a great degree, and in the severer and fatal cases may sink 
to a few ounces in the twenty-four hours, or may even be practically sup- 
pressed. The specific gravity is in many cases higher than normal, often 
reaching 1.030 or more, and the color dark, being sometimes quite pro- 
nounced, since hemorrhages frequently occur. The amount of solids, 
especially urea, voided daring the twenty-four hours is usually decreased 
to a greater or less degree. In chronic nephritis the amount of urine is 
also at first decreased, but later becomes more abundant, though never in 
as pronounced a degree as in chronic catarrhal inflammation. The spe- 
cific gravity gradually becomes lower, until in atrophy of the kidney it is 
never more than 1.012 or considerably less. The color varies, being 



202 TJBINABY ANALYSIS AND DIAGNOSIS. 

pale in the later stages. The sediment found in the urine is always quite 
abundant, and when once separated does not readily mix with the wa- 
tery portion. 

As in catarrhal nephritis, a positive diagnosis of croupous or paren- 
chymatous nephritis is in many cases possible only from a microscopical 
examination of the urinary sediment. This will vary considerably in 
acute, subacute, and chronic cases. In this variety of nephritis the pres- 
ence of casts in larger or smaller numbers is a constant feature, without 
which the diagnosis can never be made, and the greater the number of 
casts, the worse, as a rule, the inflammation. True casts will, however, 
never be found in urine without the presence at the same time of pus- 
corpuscles and kidney epithelia, the latter not only from the convoluted 
and narrow tubules, but frequently also from the straight collecting tu 
bules, though these may be absent in mild cases. 

The varieties and sizes of the casts are of great importance for the 
diagnosis and prognosis. In strictly acute cases we will never find fatty 
or waxy casts, and only occasionally a few granular casts, while hyaline 
and epithelial casts are always present in larger or smaller numbers, and 
blood casts in the severer, hemorrhagic forms. Again, the severity of the 
process can easily be determined by the size of the casts — when the small- 
est casts from the narrow tubules alone are present in small numbers, the 
parenchymatous nephritis will be of a mild character, and recovery is the 
rule. Casts from the convoluted and narrow tubules together, the former 
being of medium size, denote a process of moderate severity; but as soon 
as the largest casts, coming from the straight collecting tubules, are pres- 
ent with the other varieties, we know that the inflammatory process has 
affected the whole kidney — that is, both cortical and pyramidal substance 
— and is a severe one; therefore, a doubtful prognosis only can be given. 

Acute Croupous or Parenchymatous Nephritis (Fig. 105). — When 
we examine the urine from a case of acute croupous nephritis, the features 
are found to be numerous and characteristic. The most pronounced ele- 
ments are undoubtedly the casts, which are seen in varying numbers in 
every field of the microscope. In such cases, two varieties of casts are 
usually found — the hyaline and the epithelial, the latter studded with 
epithelia to a greater or less degree. The more numerous the casts, the 
severer the inflammation and the more albumin the urine usually con- 
tains. 

Besides the casts, pus-corpuscles, red blood-corpuscles, and epithelia 
from the convoluted tubules are always present. They are found in mod- 
erate or large numbers, the kidney epithelia being frequently seen massed 
together. Red blood-corpuscles are found in every field, though, uness 
a hemorrhage has taken place, they cannot be called very abundant. 




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Revised by 

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'rofessor of Physiology, University of Buffalo, 



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Fig. 105. — Acute Croupous or Parenchymatous Nephritis, with Catarrhal Pye- 
litis and Cystitis (X 500). 

RB, Red blood-corpuscles; PC, pus-corpuscles; CE, epithelia from the convoluted 
tubules of the kidney; ES, epithelium from the straight collecting tubules of the kidney; 
UE, epithelia from the ureter; PE, epithelia from the pelvis of the kidney; UB, epithelia 
irom the upper layers of the bladder; MB, epithelia from the middle layers of the bladder; 
CC, creatinin crystals; HC, hyaline casts; EC, epithelial cast; MT , mucus-thread; MC, 
mucus-cast, CT, connective-tissue shred. 



DISEASES OF THE KIDNEY AND PELVIS. 205 

Epithelia from the straight collecting tubules may also be seen, and those 
from the ureter and pelvis of the kidney almost invariably accompany the 
other features. In some cases, there will also be an accompanying acute 
cystitis, shown by the presence of epithelia from the upper and middle 
layers of the bladder. 

In these acute cases, mucus is present in fairly large amount, the pale 
strings being sometimes of considerable size, irregular, and finely striated. 
Not infrequently mucus is found in the form of casts — the so-called cylin- 
droids. The presence of these has no further significance than the pres- 
ence of mucus in general, and they may be seen in inflammations of any 
one of the geni to-urinary organs. When they exist in a characteristic form, 
they can hardly be mistaken, as they are always faintly striated; but not 
infrequently they are so faint that their striation becomes visible only 
upon sharp focusing, and caution is here necessary not to mistake them 
for hyaline casts, which is frequently done. In size and shape they may 
resemble hyaline casts, which latter, however, are never striated. When 
they assume an irregular, convoluted form their diagnosis is easy. 

In the severer cases of acute croupous nephritis small shreds of con- 
nective tissue will be present; they are never large or numerous, and their 
higher refraction and pronounced fibrillary structure are sufficient to dif- 
ferentiate them from mucus. Besides these features, crystals of creatinin 
may be present in intense cases in which ursemic convulsions not rarely 
develop. The illustration is taken from a, case of severe nephritis, which 
developed in the third week of scarlet fever and caused the death of the 
patient. The urine contained large numbers of characteristic creatinin 
lozenges and plates. 

Besides the cases just described, severe cases with pronounced hemor- 
rhages are often seen, and will give somewhat different features (Fig. 106). 

The urinary sediment contains a large number of red blood-corpuscles 
in every field, together with many blood casts. The blood casts are partly 
filled with red blood-corpuscles, which have retained their normal ap- 
pearance, and partly with disintegrated blood-globules, in the form of ir- 
regular brown masses, giving to the whole cast a rust-brown appearance; 
blood casts assume this character when they have been retained in the 
tubules for some time. Sometimes the larger portion of the cast contains 
fully formed red blood-corpuscles, while the disintegration has com- 
menced in a small portion. Besides these casts, hyaline and epithelial 
2asts are found in large numbers, and in these cases we almost invariably 
find large casts from the straight collecting tubules. 

Epithelia from the straight collecting tubules are usually quite abun- 

ant, and connective-tissue shreds are larger and more numerous than in 

the preceding. In an active hemorrhage such connective-tissue shreds 



>. 



206 URINARY ANALYSIS AND DIAGNOSIS. 

are cast off in fair numbers and found in the urine. Sometimes masses 
of fibrin are also found. The other features are the same, there being 
in most cases an accompanying inflammation of the pelves, the ureters 
and the bladder. 

Subacute Croupous Nephritis (Fig. 107). — After a croupous or par- 
enchymatous nephritis has lasted for some time, the casts, or rather som 
of the casts, commence to change. Such a change is rarely noticed until 
four or six weeks after the commencement of the inflammation, but occa-* 
sionally, especially in nephritis after scarlet fever in children, may take 
place in one or two weeks. 

The first change will be seen in the epithelial casts, some of the epi- 
thelia breaking down into granules, giving us an epithelial-granular cast. 
Very soon, however, perfect granular casts, without any trace of epithe- 
lia, are also found in small or moderate numbers, and these, in exceptional 
cases in children, can be seen as early as one week after the inflammation 
has started, being then scanty. 

The next change which takes place is the transition of the granul 
into glistening, refractive fat-granules and -globules, at first only two o: 
three being noticeable in a granular cast, and later on a larger number. 
Traces of the original epithelia may still be seen in the cast, while the 
largest portion has become changed into granules, and some of the gran- 
ules into fat-globules, and we now have epithelial-granular-fatty casts. 
When the inflammation has lasted for six weeks or two months, small 
groups of free fat-globules, at first scanty, are also found, and a few glob- 
ules are seen in the epithelia. 

The other features, usually present in moderate numbers only, are the 
same as in an acute croupous nephritis, and connective-tissue shreds are 
scanty, unless the case is a severe one. Mucus-threads and -casts may at 
times be pronounced, and the accompanying inflammations, especially in 
the bladder, are well marked. 

Chronic Croupous Nephritis. — The longer a nephritis lasts, the more 
marked are the changes in the casts, and in strictly chronic cases neither 
hyaline nor epithelial casts are seen in the urine. The granular casts are 
the most abundant in the milder forms, though a few fatty casts or gran# 
ular-fatty casts are also present. The groups of free fat-globules, as well 
as the fat-globules in the epithelia and pus-corpuscles, become more nu- 
merous and more pronounced. 

In almost all cases of chronic croupous or parenchymatous nephritis, 
which have lasted for many months, and instead of abating have becomi 
more pronounced, a fatty degeneration of the kidney will develop, and we 
now have the so-called large white kidney (Fig. 108) . 

In these cases the fatty casts are abundant, and the large casts from 




?ig. 106. — Acute Hemorrhagic Croupous or Parenchymatous Nephritis, with 
Catarrhal Pyelitis and Cystitis (X 500). 
RB, Red blood-corpuscles ; PC, pus-corpuscles, CE, epithelia from the convoluted 
tubules of the kidney; SE, epithelia from the straight collecting tubules of the kidney; 
UE, epithelia. from the ureter; PE, epithelia from the pelvis of the kidney; UB, epithelia 
[rom the upper layers of the bladder; MB, epithelia from the middle layers of the bladder; 
|7C, hyaline casts; EC, epithelial cast; BC, blood casts; CT, connective-tissue shred; 
jkf C, mucus-cast. 




EGF 



ig. 107. — Subacute Croupous or Parenchymatous Nephritis, with Catarrhal 
Pyelitis and Cystitis (X 500). 
RB, Red blood-corpuscle; PC, pus-corpuscles; CE, epithelia from the convoluted 
xbules of the kidney; SE, epithelium from the straight collecting tubules of the kidney; 
E, epithelia from the ureters ; PE, epithelium from the pelvis of the kidney ; UB, epi- 
lelia from the upper layers of the bladder ; MB, epithelia from the middle layers of the 
adder; HC, hyaline cast; EC, epithelial cast; GC, granular-cast ; GF, granular-fatty 
ist; EGF, epithelial-granular-fatty cast; MT , mucus- thread ; MC, mucus-cast; CT , 
>nnective- tissue shred; FG, free fat-globules. 

14 



DISEASES OF THE KIDNEY AND PELVIS. 211 

the straight collecting tubules are frequently seen in conjunction with the 
smaller casts. The fatty changes in the pus-corpuscles and epithelia are 
,vell marked, and the groups of free fat-globules and -granules are large 
|md numerous. Here, too, individual fat-globules, much larger than those 
Ordinarily seen, and sometimes attaining three or four times their size or 
ven more, may be present. In rare cases needles of margaric acid in 
mall numbers are found, but these are exceptional. Red blood-corpus- 
les are scanty in the majority of these cases. 

Connective-tissue shreds are usually present, but, as a rule, are small 
nd not numerous. The evidences of chronicity, as shown by the fat- 
lobules, will be seen in all epithelia found in the urine; that is, both 
hose from the convoluted and straight collecting tubules of the kid- 
ey, from the pelvis, the ureters, and the bladder. The epithelia from the 
traight collecting tubules are sometimes numerous, and may be just as 
bundant as the cuboidal epithelia. Pelvic epithelia are never absent, 
nd those from the ureters are well marked. That a cystitis of varying 
egrees of intensity is always present need hardly be mentioned. 

Besides the fatty degeneration, a waxy or amyloid degeneration of the 
idney is found in a number of cases. Some authors call this an amyloid 
isease of the kidney, and claim that it is an independent affection and 
ot associated with a parenchymatous nephritis. This view is undoubt- 
ily incorrect, as a waxy degeneration of the kidney is always a second- 
ly affection found in chronic cases of nephritis. The exact cause and 
ature of such a degeneration are not known, and it is mostly found in 
ironic diseases, such as syphilis, tuberculosis, suppurative processes, 
Icerations, and necroses. It seems to be due to some chemical 
lange in the plasma of the blood, though the nature of this change is 
nknown. 

Waxy degeneration of the kidney may occur in both catarrhal and 
•oupous nephritis ; it is much more common in the latter, and is rare in 
le former. It invades the epithelia of the uriniferous tubules, and ulti- 
mately produces waxy casts. Epithelia which have become waxy are 
ghly glistening, and are found in the urine as more or less shining, 
)mogeneous bodies. Not only the epithelia, but also the connective 
ssue, and simultaneously the walls of the blood-vessels, may undergo 
axy degeneration. 

The appearance of the urine is not characteristic of this degeneration, 
id it will present the features of a chronic nephritis, though the amount 
sediment greatly varies, being sometimes slight, sometimes abundant, 
tie specific gravity is usually low, and the amount of urine voided above 
)rmal. The diagnosis should never be made unless the changes in the 
inary features are pronounced, and care must be taken not to mistake 



212 URINARY ANALYSIS AND DIAGNOSIS. 



hyaline casts, which may in rare cases be somewhat glistening, for waxy 
casts. 

In chronic croupous nephritis with waxy degeneration of the kidney, 
the most characteristic features are the waxy casts (Fig. 109). 

Waxy casts may occur in all sizes, are always of a high refraction, 
have wavy, convoluted contours, and frequently a yellowish color. The 
casts may assume different forms, and not rarely are so tortuous as to be 
likened to a corkscrew. In most cases all the three sizes of waxy casts 
will be found, and they may sometimes be mixed with other elements, 
such as granules — the granular-waxy; or with fat-globules — the fatty- 
waxy casts. The other features are the same as those in any chronic 
croupous nephritis. Pus-corpuscles are always present, as well as differ- 
ent epithelia, connective- tissue shreds in large numbers, and granular as 
well as fatty casts. The appearance of a waxy degeneration is usually 
of grave import, though even here recoveries have occurred, especially 
in children. 

Cystic degeneration, which is also a secondary change, found ir 
chronic cases of nephritis, does not give any characteristic symptoms ir 
the urine, and, therefore, cannot be diagnosed as such. 

Atrophy of the Kidney. — The result of a chronic croupous or paren- 
chymatous nephritis is invariably atrophy of the kidney. The feature! 
of atrophy, as found in the urine, are characteristic, and a positive diag- 
nosis can always be made, though the amount of urine voided in th< 
twenty-four hours varies, is never as abundant as in cirrhosis of the kid 
ney, and is usually considerably below the normal amount. The feature; 
are the following: 

1. A continuously low specific gravity, as a rule never above 1.010 1 
and occasionally not more than 1.006 or 1.004 at any time. 

2. The presence of a large amount of albumin, in contradistinction t< 
the small amount found in cirrhosis. 

3. A considerable diminution of all salts. 

4. Pus-corpuscles, present in moderate numbers, many, if not all, co 
taining fat-granules and -globules. 

5. Epithelia from the convoluted and straight collecting tubules of t 
kidney, in moderate numbers, many or all containing fat-granules am I 

-globules. 

f 

6. Free fat-granules and -globules, sometimes in large numbers. 

7. Granular, fatty, and in some cases even waxy casts in varyin 
numbers, the former being usually quite abundant. 

8. Connective-tissue shreds of moderate or large size, and always i j L 
at least fair numbers. }■ 

9. Broken-down or poor constitution, as seen by the pale, fmel \ 



I 




ig. 108. — Chronic Croupous or Parenchymatous Nephritis, with Fatty De- 
generation of the Kidney, Accompanying Catarrhal Pyelitis amd Cystitis 

(X 500). 
PC, Pus-corpuscles; CE, epithelia from the convoluted tubules of the kidney; SE, 
>ithena from the straight collecting tubules of the kidney; UE, epithelium from the 
reter; PE, epithelia from .the pelvis of the kidney; MB, epithelia from the middle 
yers of the bladder; GC, granular cast; FC, fatty casts; GF, granular-fatty casts; 
T, connective-tissue shreds; FG, free fat-globules. 



wc 




WF 



FC 
SE 



Fig. 109. — Chronic Croupous or Parenchymatous Nephritis, with Fatty and 
Waxy Degeneration of the Kidney, Accompanying Catarrhal Pyelitis ( X 500). 
P, Pus-corpuscles; CE, epithelia from the convoluted tubules of the kidney; SE, 
epithelia from the straight collecting tubules of the kidney; UE, epithelia from the 
ureter; PE, epithelia from the pelvis of the kidney; GC, granular cast; GF, granular- 
fatty cast; FC, fatty cast; WC, waxy cast; WF, waxy-fatty cast; MC, mucus-cast; 
CT, connective-tissue shred; FG, free fat-globules. 



DISEASES OF THE KIDNEY AND PELVIS. 217 

granular pus-corpuscles, in which one or more nuclei are usually 
visible. 

Epithelia from the pelvis of the kidneys, the ureters, and the middle 
layers of the bladder will be present in variable numbers. 

Here, again, attention must be called to the fact that a badly diseased 
kidney, as an atrophied kidney always is, can never void many salts. In 
those cases in which the specific gravity is higher, and uric-acid, calcium- 
oxalate, or phosphate crystals are seen under the microscope, though all 
the other features admit of a positive diagnosis of atrophy of the kidney, 
we can reach the conclusion that only one kidney is as yet affected, since 
the salts must be voided by the other kidney. In such cases it will al- 
ways be noticed that the constitution, although greatly impaired, cannot 
as yet be called poor, since, though many pus-corpuscles are finely granu- 
lar and pale, some will still show a moderately coarse granulation. The 
prognosis in all such cases is considerably better than when no salts what- 
ever are seen. 

Chronic Croupous Nephritis, with Acute Croupous Exacerbation. — In 
many cases of chronic croupous nephritis, acute exacerbations may occur 
at any time, and fresh portions of the kidney tissue become inflamed. 
Such acute exacerbations can, in some individuals, be produced upon the 
slightest cause, as exposure to cold or errors in diet. It is not uncommon 
for an exacerbation of this kind to be produced every few weeks or 
months, leaving the patient weaker every time, and finally resulting in 
death. 

A case of this kind, in which an acute croupous hemorrhagic exacer- 
bation took place in a young man of twenty years, is shown in Fig. 110. 

In this case, which ended fatally, all six varieties of casts, and of all 
three sizes, were present in large numbers. Not only were the regular 
casts seen, but a number of different combinations. The casts present 
were hyaline, epithelial, blood, granular, fatty, waxy, granular-fatty, epi- 
thelial-waxy, blood-waxy, and fatty-waxy. 

Red blood-corpuscles were present in every field in moderately large 
numbers, and variously sized groups of fat-globules were also abundant. 
Pus-corpuscles were numerous, and epithelia from the convoluted as well 
as the straight collecting tubules of the kidney were present in large num- 
bers, many studded with fat-globules. Connective-tissue shreds were 
present, and mucus in the form of threads, and especially casts, could be 
seen in many fields. Of the accompanying inflammations, the pyelitis 
was the most severe, though the inflammations of the ureters and bladder 
were well marked. 

Salts were entirely absent under the microscope and the constitution 
was very poor. The diagnosis that probably both kidneys were affected 



218 UE1NABY ANALYSIS AND. DIAGNOSIS. 

in a severe degree was made, and a bad prognosis had to be given. The 
patient died within two weeks after the examination. 

From the descriptions here given, it will be seen that the varieties of 
casts found in croupous or parenchymatous inflammations of the kidney 
tend to show whether the process is acute, subacute, or chronic. When 
hyaline, epithelial, or blood casts are found in a case giving all the symp- 
toms of chronicity, we can be certain either that an acute exacerbation has 
taken place in the same kidney or that the second kidney has become 
acutely inflamed. Sometimes cases of a so-called acute inflammation 
show granular and even fatty casts in large numbers, but careful ques- 
tioning of the patient will bring out the fact that he has not been perfectly 
healthy for a long time, though he may have been able to attend to his 
business in spite of headache and general malaise. The only cases in 
which purely granular casts in small numbers may occasionally be seen 
one or two weeks after the commencement of the inflammation, are those 
already mentioned, especially in children after scarlet fever. Waxy casts 
never appear in acute inflammations, but always denote chronicity. 

SUPPURATIVE NEPHRITIS. 

Suppurative nephritis, also called abscess of the kidney, or surgical 
kidney, the most intense of the three primary varieties of nephritis, is an : 
independent process, and must not be confounded with acute interstitial 
nephritis or non-suppurative pyelo-nephritis. There may be either a 
number of small, disseminated foci of suppuration, or one large abscess, j 
usually confined to one kidney. Sometimes the suppuration may be so 
excessive that the larger part of the structure of the kidney has disap-: 
peared, and a large, thick-walled cavity filled with pus is found in its} 
place; these cases are spoken of as pyonephrosis. 

Causes. — The causes of a suppurative nephritis are not always plain, 
though in many cases the disease is the result of an extension of the in- 
flammatory process from some other portion of the genito-urinary tract. 
A simple gonorrhoea, which gradually extends upward, may be sufficient 
to cause it, and both urethral strictures, and inflammation and hypertro- 
phy of the prostate gland may be causes. The use of unclean sounds and 1 
catheters, even in these days of antisepsis, is not rarely followed by an 
abscess of the kidney. 

Occasionally the disease follows different acute infectious diseases, 
such as typhus and typhoid fevers, cholera, and diphtheria, or may be 
seen with pyaemia and carbuncles. In renal tuberculosis abscesses are 
quite common, and they may also occur when calculi are present. In 




Fig. 110. — Chronic Croupous or Parenchymatous Nephritis, with Fatty and 
Waxy Degeneration of the Kidney and an Acute Hemorrhagic Croupous 
Exacerbation, Catarrhal. Pyelitis, and Cystitis (X 500). 

RB, Red blood-corpuscles; PC, pus-corpuscles; CE, epithelia from the convoluted 
tubules of the kidney; SE, epithelia from the straight collecting tubules of the kidney; 
TJE, epithelia from the ureter; PE, epithelia from the pelvis of the kidney; UB, epithelium 
from the upper layers of the bladder; MB, epithelium from the middle layers of the blad- 
der; HC, hyaline cast; EC, epithelial cast; BC, blood-cast; GC, granular cast; FC, 
fatty cast; FW, fatty-waxy cast ; EW , epithelial- waxy cast ; CT, connective-tissue shred; 
MT, mucus-thread; MC, mucus-corpuscle; C, mucus-cast; FG, free fat-globules. 



DISEASES OF THE KIDNEY AND PELVIS. 221 

still other cases the etiology remains obscure, and we can only surmise 
that pyogenic organisms in large numbers have settled in a perhaps pre- 
viously inflamed kidney. 

Clinical Symptoms. — Acute abscesses are usually ushered in by pro- 
nounced chills, followed by a rise in temperature and general depression. 
Pain, as a rule, is present, although it is not always referred to the seat of 
the abscess. Emaciation, nausea, and vomiting can occur. After an ab- 
scess has ruptured, it may continue to discharge pus for a long time, be- 
coming chronic. In these cases the acute symptoms gradually subside, 
though a slight fever is always present, and pain or tenderness either in 
the region of the kidney or in the inguinal region, testicles, or legs is a 
constant feature. 

Features Found in Urine. — The urine in suppurative nephritis is always 
cloudy, and a pronounced heavy sediment invariably forms. The spe- 
cific gravity varies considerably, but is mostly below normal, and the 
amount of urine is diminished. Albumin is present in large amount in 
every case. 

The clinical symptoms are at times so vague that a positive diagnosis 
is generally possible only through a microscopical examination of the uri- 
nary sediment. The features found under the microscope will at once 
clear up the diagnosis, and it does not seem necessary for the abscess to 
have ruptured ; emigrated pus-corpuscles and the shedding of connective- 
tissue shreds are sufficient for a diagnosis as long as no firm membrane 
has formed around the abscess. 

The microscopical features are the presence of a large number of pus- 
corpuscles, many kidney epithelia, usually from both the convoluted and 
straight collecting tubules, and a varying number of red blood-corpuscles, 
the latter being quite abundant in acute abscesses. Besides these, con- 
nective-tissue shreds are always found, in either moderate or large amount. 
Without such shreds, abscess of the kidney should never be diagnosed, 
since these alone show a destruction of the kidney tissue. Epithelia from 
the pelvis of the kidney almost invariably accompany the affection. Casts 
may be either present or absent; when present, they denote a complicat- 
ing croupous nephritis. 

The features seen in a chronic suppurative nephritis are shown in Fig. 
111. 

The pus-corpuscles are extremely numerous, and may so entirely fill 
some fields that no other features become visible. In other fields, how- 
ever, epithelia from the convoluted tubules of the kidney will be found in 
large numbers, and, as a rule, those from the straight collecting tubules 
are also present. Fat-globules and -granules are abundant, partly lying 
free in variously sized groups, partly filling the pus-corpuscles and epithe- 



222 UEINABT ANALYSIS AND DIAGNOSIS. 

lia to a greater or less degree. Connective-tissue shreds are present, being 
large and abundant. 

Red blood-corpuscles are always found, but in such cases in small 
numbers only, while not infrequently rust-brown crystals of hsematoidin, 
in the form of needles and plates, but especially the former, denoting a 
previous hemorrhage, are seen. These will be found in the pus-corpuscles 
and epithelia, as well as free. In the case depicted, the hsematoidin crys- 
tals are very abundant, being found in the form of large conglomera- 
tions of irregular, curved needles and stars, as well as smaller plates. 
Epithelia from the pelvis of the kidney, the ureter, and the bladder, de- 
noting an inflammation of these organs, are also fairly numerous. In 
addition, numerous bacteria are usually present. 

Although these features are perfectly characteristic, we not infre- 
quently find another, the so-called endogenous new-formation of pus- 
corpuscles in different kidney and even pelvic epithelia, denoting, if pres- 
ent in large numbers, a pressure. Such a diagnosis will, therefore, hardly 
ever present any difficulties, contrary to the opinion frequently held that 
it is impossible to diagnose an abscess from the examination of the urine 
alone. 

Abscesses not directly in the kidney substance, but pressing upon the 
kidney — perirenal abscess — may also be diagnosed. These will show the 
same features in the urine, though perhaps somewhat less marked, to- 
gether with endogenous new-formations in the kidney epithelia. When- 
ever these are seen in many epithelia, they are caused by long-continued 
pressure upon the kidney, and their presence justifies the diagnosis. 

SUPPURATIVE PYELITIS. 

An abscess may develop in the pelvis of the kidney instead of in the 
kidney proper. The causes of this are the same as for suppurative nephri- 
tis, though perhaps calculi will more frequently produce an abscess here 
than in the kidney proper. The symptoms do not differ from those of 
suppurative nephritis, and the exact location of the abscess can only be 
determined by microscopical examination of the urine (Fig. 112). 

In an acute suppurative pyelitis, red blood-corpuscles are always pres- 
ent in moderate or even large numbers, and pus-corpuscles are extremely 
numerous. The diagnosis can be made from the cuboidal and irregular 
pelvic epithelia, which in these cases are abundant, and may be found in 
groups. In such abscesses epithelia from all the different layers of the 
pelvis will be present. These epithelia may vary considerably in size, and 
a few may be even as large as those from the middle layers of the bladder. 
There should, however, be no difficulty in diagnosing them, since these 




Fig. IH.-Cheonic Suppurative Nephritis, with Catarrhal Pyelitis (X 500). 
RB, Red blood-corpuscle; PC, pus-corpuscles; CE, epithelia from the convoluted 
tubules of the kidney; SE, epithelium from the straight collecting t^ 1 ^*^ 1 ^ 
UE, epithelia from the ureter; PE, epithelia from the pelvis of the -kidney, CT, con 
nective-tissue shreds; HC, hsematoidin crystals; FG, free fat-globules. 



DISEASES OF THE KIDNEY AND PELVIS. 225 

large epithelia are irregular, angular, lenticular, or pear-shaped. Connec- 
tive-tissue shreds are numerous, and without them no such diagnosis must 
be made. 

In all cases epithelia from the ureter, showing a secondary inflamma- 
tion, are quite abundant, and in many of them endogeneous new-forma- 
tions of pus-corpuscles will be found. Epithelia from the convoluted 
tubules of the kidney need not necessarily be present in acute cases, but 
sooner or later a moderate number, the indication of an accompanying 
nephritis, are seen; here, too, endogenous new-formations can appear. 
Very soon a cystitis will develop, and the epithelia from the bladder ac- 
company the other features. 

In a chronic abscess of the pelvis the features are the same as those 
described in suppurative nephritis, except that the comparative number 
of the pelvic and kidney epithelia becomes changed, the former being 
considerably more numerous than the latter. 

TUBERCULOSIS OF THE KIDNEY. 

Although renal tuberculosis can undoubtedly exist as a primary dis- 
ease, it is comparatively rare, being most frequently associated with tu- 
berculosis in other organs. It may result from an extension of the tuber- 
cular process from other portions of the geni to-urinary tract. In the 
kidney we will generally find evidences of a chronic catarrhal or inter- 
stitial nephritis, though in rare cases a croupous or parenchymatous in- 
flammation accompanies the tubercular process. The tubercular nodules 
in different portions of the kidney enlarge, and, after a time, usually break 
down, so that ulcers or abscesses are formed. 

Features Found in Urine. — The appearance of the urine is not charac- 
teristic in these cases; the color is usually pale, and it is turbid and of a 
low specific gravity. The amount of urine is increased, and a small 
amount, sometimes only a trace, of albumin is present. The sediment is 
slight, unless ulcers or abscesses have formed, when it is more profuse. 

The features under the microscope are at first those described in a 
chronic catarrhal nephritis, and later on give evidences of a destructive 
process, with the presence of connective-tissue shreds in varying amount. 
In most cases a pronounced cystitis is associated with the process, and 
not rarely ulcers will be formed in the bladder. Such a chronic ulcerative 
cystitis should always be looked upon with suspicion, as being possibly 
due to a tuberculosis. 

Whenever tuberculosis is suspected in the kidneys, and the evidences 
of a chronic interstitial nephritis are found in the urine, examinations for 
tubercle bacilli must be made. This is not infrequently a tedious process, 
15 



226 URINARY ANALYSIS AND DIAGNOSIS. 

as the bacilli are rarely present in large numbers; yet the diagnosis can 
not be made with certainty without them. Repeated examinations o 
many drops, from urine taken at different times of the day, will neve 
fail to reveal them. 

Too much stress cannot be laid upon the constitution of the patient 
as shown by the appearance of the pus-corpuscles, in such cases. As Ion 
as the larger numbers of the pus-corpuscles are coarsely granular anj 
glistening, showing a good constitution, the presence of tuberculosis i 
not probable. As soon, however, as the pus-corpuscles, or a large numbe 
of them, are pale and finely granular, showing a considerably impaired cj 
poor constitution, the existence of a possible tuberculosis must not be los 
sight of. Such a poor constitution, with the evidences of only a moderat 
catarrhal nephritis and cystitis, may not infrequently be among the firs 
suspicious signs of tuberculosis, even when the clinical symptoms are {■ 
yet only slightly pronounced. 









sc: 




Fig. 112. — Acute Abscess of Pelvis of Kidney, or Acute Suppurative Pyelitis 

(X 500). 
RB, Red blood-corpuscles ; PC, pus-corpuscles ; UE, epithelium from the ureter ; PE,. 
epithelia from the pelvis of the kidney; CE, epithelia from convoluted tubules of the 
kidney; CT, connective- tissue shreds. 



DISEASES OF THE KIDXEY AND PELVIS. 229 



II. ANOMALIES OF SECRETION. 

Of great importance in the diagnosis of kidney lesions are the anom- 
.lies of secretion, under which term the conditions known as lithcemia and 
■xaluria are included. Sooner or later these will in many cases produce 
.n inflammation of the kidney proper, as well as the pelvis of the kidney, 
md may in pronounced cases cause hemorrhages from the kidney and 
>elvis, as well as abscesses. 

Both lithsemia and oxaluria are of frequent occurrence, and need not 
f necessity lead to the production of calculi, though this may occur. 
D ersons so affected will pass large quantities of uric acid or calcium oxa- 
ate, or both, and their urine almost invariably has a high specific gravity. 

Causes. — The causes of these conditions are practically unknown. It 
vas believed that persons who live high, eat an excessive amount of 
neat as well as starchy and saccharine substances, and drink considerable 
champagne are predisposed to the so-called uric-acid diathesis. This is 
Imdoubtedly true in some cases; but in others just the opposite condi- 
ions prevail, and still uric acid is voided in large amounts. 

Clinical Symptoms. — The clinical symptoms in these cases, which are 
much the same in both conditions, are headache, general malaise, dys- 
sepsia, irregularity of the bowels, sleeplessness, neurasthenia, and later on 
melancholia, Frequent urination with a burning sensation in the urethra 
may be present, and there is often a dull, aching feeling in the lumbar 
region. In lithsemia fleeting pains in legs, knees, hands, and arms may 
also exist. Persons so affected are always irritable, and sooner or later 
suffer from neurasthenia and melancholia; they may be treated for a va- 
riety of affections before the true cause of their condition is discovered. 

LITH^MIA. 

The microscopical features in the urinary sediment of a person affected 
with lithsemia are quite characteristic (Fig. 113). 

Crystals of uric acid are found in large numbers, and as a rule different 
varieties, such as the common form, that seen in highly acid urine, and 
irregular plates and needles, are present. The crystals may attain large 
sizes, but usually the smaller sizes only are met with. Besides these, 
crystals of calcium oxalate in moderate numbers are also present. In 
many cases which come under observation pus-corpuscles are found in 
small or moderate numbers, as well as different epithelia, more especially 
those from the pelvis of the kidney and the ureters, though epithelia from 
the convoluted tubules in small numbers and bladder epithelia are rarely 



230 URINARY ANALYSIS AND DIAGNOSIS. 






absent. Red blood-corpuseles are not numerous when no hemorrhage has 
taken place, though a few are always seen. A few fat-globules are usually 
seen in the pus-corpuscles and epithelia. 

In these, the common cases of lithsemia, we have, therefore, an in- 
flammation of moderate severity only, either a simple pyelitis or a pyelo- 
nephritis, with an accompanying cystitis. The inflammation, when seen, 
is rarely acute, but usually subacute or chronic. Such a condition may 
go on for many years without producing any other features. 

When large numbers of these salts are continually produced arid de-i 
posited in the pelves and calices of the kidneys, smaller or larger concre- 
tions or calculi will then be formed, and cause more pronounced symp- 
toms. In such cases the first symptom is not infrequently a hemorrhage 
from the kidney or pelvis, with more or less severe pain. All the features 
of such a hemorrhage, together with concretions of uric acid, will be found 
in the urine. After a day or two the symptoms may subside, but, if the 
causes leading to the formation of the salts still continue, will recur sooner 
or later. 

Hemorrhage from the Pelvis of the Kidney. — Hemorrhage from the] 
pelvis of the kidney, due to uric-acid calculus, gives characteristic feat- 
ures in the urine, from which the diagnosis can easily be made (Fig. 114).! 

The field is crowded with red blood-corpuscles, which vary very con- 
siderably in shape, size, and appearance. As the urine is usually not ex- 
amined until a number of hours after it is voided, comparatively small 
numbers will be found containing haemoglobin, and they are therefore of a 
yellowish or slightly brown color. The larger numbers usually have lost' 
the haemoglobin, and these corpuscles will appear colorless, with a distinct 
double contour. They are found either singly or conglomerated in large 
groups. Crenated red blood-corpuscles are frequently found, but in small 
numbers only, and they may also be seen edgewise. When they have im- 
bibed water, they swell, and may be even double their usual size. Again, 
a varying number of haematoblasts, which present the features of red I 
blood-corpuscles, but are only half their size, are often seen in an active 
hemorrhage. White blood-corpuscles, which may be twice the size of the 
fully formed red blood-globules, and cannot be distinguished from pus- 
corpuscles, are present in small numbers. They are always granular, 
either pale with a fine granulation or more glistening and having a coarser 
granulation. When comparatively few of these corpuscles are seen, we 
know that they are not pus-corpuscles, and their presence should never 
cause the diagnosis of an inflammation. 

Besides the blood-corpuscles, uric-acid crystals, in the form of irregu- 
lar plates, masses, and needles, are abundant. They vary considerably 
in size, are always colored, and may be either single or conglomerated. 




Fig. 113. — Lith^emia, with Subacute Catarrhal Pyelitis and Cystitis (X 500). 

UA, Uric-acid crystals; OC, calcium-oxalate crystals; RB, red blood-corpuscle ; PC, 

pus-corpuscles; PE, epithelia from the pelvis of the kidney; UE, epithelium from the 

ureter; UB, epithelium from the upper layers of the bladder; MB, epithelium from the 

middle layers of the bladder. 



DISEASES OF THE KIDNEY AND PELVIS. 233 

The needles may be seen in groups containing individual small formations, 
which sometimes appear like small granules, or they are large and form 
stellate masses. These are the forms which, when small, produce gravel; 
when large, are portions of calculi, and may lodge in the pelvis of the 
kidney. 

Epithelia from the pelvis of the kidney, varying in size but always 
characteristic, are more or less numerous. When the hemorrhage is se- 
vere, many fields may sometimes have to be examined before they are 
discovered, and the place of origin of the hemorrhage becomes clear; but 
they are always present, often in groups of three, four, or more. Smaller 
epithelia from the ureter are also seen. Connective- tissue shreds are 
never absent, though their number and size may be small. In pronounced 
cases they are usually found in large numbers. 

Besides these features, variously sized masses of fibrin, in the form of 
thin, pale, often colorless strings, consisting of wavy bands, may some- 
times be seen, and irregular clots of blood can also be found. In such 
hemorrhages all the features, including the epithelia and connective-tis- 
sue shreds, may occasionally have a yellowish color from the haemoglobin; 
but this is not the rule, unless the centrifuge has been used and the exam- 
ination made immediately after the urine is passed. 

Pyelitis Calculosa. — In the so-called pyelitis calculosa, an inflamma- 
tion or even suppuration of the pelvis is present, and due to calculi, the 
most common of which are uric acid and calcium oxalate, though phos- 
phatic stones are also not rare. The features are the same as those found 
in any catarrhal or suppurative pyelitis, with the addition of concretions. 
Red blood-corpuscles are invariably present in such cases, but, unless a 
hemorrhage occurs in the course of the inflammation, never in large 
numbers. 

OXALURIA. 

Among the anomalies of secretion, oxaluria plays an important part. 
It is far more common than is generally supposed, and in all cases giving 
vague neurasthenic symptoms the urine should be examined. The spe- 
cific gravity is usually high, not infrequently 1.030 or even 1.040, and the 
amount of urine passed does not vary much from the normal. The mi- 
croscope always shows large numbers of crystals of calcium oxalate, in 
all shapes and sizes, and even in the milder cases an irritation of the pel- 
vis of the kidney is rarely absent, so that a small number of pus-corpus- 
cles and pelvic epithelia is found. Instead of a plain irritation, all the 
grades of inflammation may at different times exist, though oxaluria 
alone, without the presence of a stone, does not cause suppuration. 

When many crystals are present, minute concretions, which are so small 



234 URINARY ANALYSIS AND DIAGNOSIS. 

as to give no special symptoms, are frequently passed, and these, in aj 
few cases, may cause hemorrhages from the pelvis. In a number of cases 
which have come under observation, prolonged hematuria existed, but 
the cause could not be discovered, as there was no pain connected with it 
and no symptom to suspect the presence of a calculus. Microscopical ex- 
amination showed those minute concretions, and easily cleared up th( 
case. 

HEMOGLOBINURIA. 

Hemoglobinuria is a rare condition, which is characterized by a di 
solution of the red blood-corpuscles and the appearance in the urine 
the coloring matters of the blood in solution. The red color of the urin 
which is always found in these cases is, therefore, not due to the presence 
of a large number of red blood-corpuscles, as in hematuria, but to that 
of dissolved haemoglobin. 

Causes. — The affection is occasionally seen after poisoning with differ- 
ent substances, such as carbolic acid, sulphuric acid, naphthol, muriatic 
acid, pyrogallic acid, and even chlorate of potash. It may occur in the 
course of severe infectious and contagious diseases, such as hemorrhagic 
variola, malignant scarlatina, and yellow fever, as well as in intense mal- 
aria. After extensive burns, in scurvy, and purpura it has also been 
described. 

Besides these, it may occur as an idiopathic disease of intermittent 
character — the paroxysmal hemoglobinuria — which is said to develop 
sometimes in rare cases of syphilis. In such cases urine containing haemo- 
globin may be voided either for a few hours only, or more rarely for days 
or even weeks, accompanying symptoms much like those of intermittent 
fever. As a rule, attacks of this kind follow exposure to cold. 

Features Found in Urine. — The appearance of the urine in hemo- 
globinuria is always dark red or brownish, the sediment being abundant. 
The specific gravity varies considerably, but, as a rule, is slightly in 
creased. Albumin will be found in varying amount. Although the dis 
ease is by no means a distinct kidney affection, changes having taker 
place in the blood, a nephritis of varying degrees of intensity usually ac 
companies it, and its features are found in the urine. 

The microscopical elements in a pronounced case of hemoglobinuria 
which occurred in yellow fever, are illustrated in Fig. 115. 

The urinary sediment contains an extremely large number of dark o: 
rather rust-brown masses, made up of granular matter, as well as gran 
ules scattered irregularly over the field. The masses vary considerably 
in size, some being small, but others large, and may assume differen 
shapes ; these are the masses and granules of hemoglobin. 



UA 



WC- 



UA 




Fig. 114. — Hemorrhage from Pelvis of Kidney, Due to Uric- Acid Calculus 

(X 500). 
UA, Uric-acid crystals; RB, red blood-corpuscles; WC, white blood-corpuscle ; PE, 
rithelia from the pelvis of the kidney; UE, epithelium from the ureter; EC, epithelium 
om the convoluted tubules of the kidney; CT, connective-tissue shreds. 



CEH 



EHC 




Pig. 115. — Hemoglobinuria, Acute Hemorrhagic Croupous or Parenchymatous 
Nephritis, with Catarrhal Pyelitis (X 500). 
PB, Red blood-corpuscles ; PC, pus-corpuscles ; H, haemoglobin ; CE, epithelia from the 
convoluted tubules of the kidney; SE, epithelium from the straight collecting tubules of 
the kidney; CEH, epithelia from the convoluted tubules, filled with haemoglobin; PE, 
?pithelia from the pelvis of the kidney; UE, epithelia from the ureter; HC, haemoglobin 
cast; BC, blood cast; EHC, epithelial cast filled with haemoglobin; CT, connective-tissue 
shred; CH, cylindroid with haemoglobin; OC, calcium oxalate crystals. 



DISEASES OF THE KIDNEY AND PELVIS. 239 

Haemoglobin is also found in the form of casts, which appear filled 
with dark brown granules, but differ from blood casts by their greater ir- 
regularity. The latter are rarely absent, though the blood-corpuscles are 
never found fully formed in the casts, but always disintegrated, and of a 
rust-brown color. Epithelial casts are frequently present and are also 
studded with haemoglobin. 

Red blood-corpuscles are never entirely absent in these cases, though 
they are comparatively scanty, and always, even in the freshly voided 
urine, appear very pale and double contoured, having completely lost 
their coloring matter. 

Besides these features, pus-corpuscles and epithelia are present, many 
of which are entirely filled with granules of haemoglobin and have a dark 
brown color. Pus-corpuscles are fairly abundant, and epithelia from the 
convoluted and straight collecting tubules of the kidney are seen in mod- 
erate numbers. Epithelia from the ureters and the pelves of the kidneys 
are constant occurrences. 

Connective-tissue shreds are usually found, and may contain some 
granules of haemoglobin upon them. Mucus in the form of threads or 
casts may be present, studded with masses of haemoglobin. In those cases 
different salts, especially crystals of calcium oxalate and uric-acid crys- 
tals, are seen. In cases which have lasted a long time needles and plates 
of haematoidin may be found. 

CHYLURIA. 

Chyluria is characterized by the milky-white appearance of the urine, 
similar to milk or to chyle; this appearance it retains on account of the 
molecular division of the fat which it contains, even if left standing for 
days. In some cases, though not in all, chylous urine has a pink tinge, 
due to the red blood-corpuscles frequently present. 

Two varieties of the affection are recognized: The first, or tropical 
form, occurs almost exclusively in hot climates, and is due to an invasion 
of the blood and urinary tract by a parasite — the Filaria sanguinis horn- 
inis; the second, or non-tropical form, is not due to a parasite, and is so 
rare that but little is known about it. 

In most cases chylous urine contains coagula, due to a large amount 
of fibrin which is usually present. These clots form in the bladder, and 
may be so abundant as to give rise to distressing symptoms when voided. 

The features of a chylous urine are illustrated in Fig. 116. The case 
from which the illustration was drawn was that of a young man, thirty- 
three years of age, a native of Porto Rico, who had lived in the United 
States for nine years. Three years before he presented himself for exam- 



240 UBINABY ANALYSIS AXD DIAGNOSIS. 

ination he went to his native country for two weeks, and then return 
to the United States. Two months alter returning he noticed a 
appearance of his urine. The urine cleared up after a short time, 
remained clear for more than two years, when it again became milk 
The only symptoms he complained of, when he first came under observ 
tion. were pain in the back and a slight frontal headache. In appearan 
the patient was thin and delicate-looking. Upon physical examinatio 
nothing could be discovered except a slightly enlarged liver. 

Features Found in Urine. — The appearance of the urine was that 
milk in which slightly colored, pink coagula were suspended. The clo 
were numerous and greatly varied in size, the largest being removed fro 
the bottle with difficulty. They had various shapes, some resemblin 
cysts. The specific gravity was 1.015. the reaction slightly acid, and t 
urine contained one-half of one per cent of albumin. 

Under the microscope the clots proved to be masses of fibrin, e 
bedded in which large numbers of red blood-corpuscles were found, an 
in a few. also small plates of ha?matoidin. In even' field not obscured 
the fibrin, red blood-corpuscles were very abundant, lying in groups, 
well as singly, partly of a yellowish color, containing haemoglobin, 
partly colorless. Crenated red blood-corpuscles were present in modera 
numbers, and many were seen edgewise. 

Besides these, minute fat-globules and -granules were extremely n 
merous. partly in smaller or larger masses, partly lying irregularly through- 
out the field. Xowhere could larger fat-globules be seen. In some of the 
drops examined a number of parasites, the embryonal forms of the Filaria 
sanguinis, could easily be discovered: they were of different sizes. In 
one drop a group of five, embedded in or perhaps surrounded by a mass 
of fat-globules, was found. One small body, apparently an ovum, was 
also seen. 

The other features were pus-corpuscles and epithelia from the ureters 
and the middle layers of the bladder. Xeither the pus- corpuscles nor the 
epithelia were found in every drop, it being necessary to examine a num- 
ber of drops before they were seen. Connective-tissue shreds were pres- 1 
ent. though not in even" drop. Xo salts whatever could be discovered 
under the microscope. 



UE 




MB 



Fig. 116. — Chyltjria, Catarrhal Cystitis (X 500). 
FG, Free fat-globules; RB, red blood-corpuscles; F, fibrin, with red blood-corpuscles 
d haematoidin crystals; FS, Filaria sanguinis; PC, pus- corpuscles; UE, epithelium from 
ureter; MB, epithelia from the middle layers of the bladder; CT, connective-tissue 
red. 



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DISEASES OF THE KIDNEY AND PELVIS. 243 



III. MALIGNANT TUMORS OF THE KIDNEY. 

Malignant tumors of the kidney are fortunately rare, but do occur, 
ind both sarcomata and carcinomata are met with. The former may be 
bund at all ages, while the latter, which in the kidneys seem to be of 
>till rarer occurrence than sarcomata, are usually seen in persons more 
idvanced in years. The diagnosis of sarcoma of the kidney can be posi- 
ively made from the examination of the urine, while that of cancer 
night perhaps be suspected, but can hardly be made with the same de- 
cree of certainty as when it occurs in the bladder. 

Clinical Symptoms. — When a malignant tumor has lasted for some 
ime, the clinical features will become pronounced enough to lead one at 
east to suspect its presence, but in the early stages its symptoms are not 
veil defined; though even at this time characteristic features may be 
ouncl in the urine. Pain, referred either to the region of the affected 
ddney or, less clearly defined, radiating to neighboring organs, will usu- 
lly be the earliest symptom. It is mostly of a severe character, and 
nay be paroxysmally increased. 

Very soon a tumor in the region of the kidney can be mapped out, the 
latient becomes anaemic and cachectic, and gradually loses strength. If 
tot relieved by surgical procedures, the general symptoms become more 
•ronounced, and the disease, as a rule, ends fatally within one or two 
ears, although cases of sarcoma which have lasted four or five years are 
n record. 

Appearance of Urine. — The appearance of urine is not character- 
tic. Since symptoms of inflammation soon develop, the specific grav- 
:y, color, and amount of urine voided will vary with the intensity of the 
inanimation. Hemorrhages, either constant or recurring at irregular in- 
ervals, soon appear, and the urine then has the pronounced reddish or 
rown color, due to the blood. Albumin is always present in varying 
mount. 

SARCOMA. 

Sarcoma of the kidney may be found in children as well as in adults, 
he youngest case seen by the author and diagnosed from the urine hav- 
ig been in a boy of four years, the oldest in a man of sixty-five years, 
lthough the macroscopical appearance of the urine may vary consider- 
bly, the microscopical features are usually characteristic enough to ad- 
iit of a positive diagnosis. In two cases the examination of the urine 
ave the first evidence of the disease, the clinical symptoms of the pa- 
ent not being at first clear; by careful examination of the patient, how- 



Fi 



244 URINARY ANALYSIS AND DIAGNOSIS. 

ever, a tumor of the kidney could soon be mapped out, and further 
velopments proved the correctness of the diagnosis. 

Features Found in Urine. — That sarcoma of the kidney can be diag- 
nosed from the urine was first shown by Carl Heitzmann, and a number 
of cases were published by him in the year 1888. Since then other cases 
have been seen by the author, and autopsies have left no doubt of the 
correctness of his assertions. In order positively to diagnose sarcoma, we 
must find large shreds of connective tissue as well as numerous character- 
istic sarcoma corpuscles in the urine, and therefore an ulceration must! 
have taken place. It is not impossible that these corpuscles may appear j 
in the urine before ulceration has set in, perhaps by emigration; but un- 
less they are very numerous, a positive diagnosis should not be given iff 
large connective- tissue shreds are not found at the same time. It is welli; 
known that pus-corpuscles not only vary in size in different individuals, 1 
but also to a certain degree in the same individual, and that pus-corpus- 
cles, which are as yet not fully formed and appear as small, compact, 01 
vacuoled bodies, may be found. These should not be mistaken for sar- 
coma corpuscles. 

The features found in a urinary sediment in sarcoma of the kidney are 
depicted in Fig. 117. 

We see extremely large shreds of connective tissue, which in place* 
appear more coarsely granular than usually, and may form regular coils ir 
different -portions. Occasionally these shreds will contain a small numbei 
of inflammatory corpuscles. Besides the shreds, small, globular, coarselj 
granular, glistening, even homogeneous corpuscles, without nuclei anc 
having sharply defined contours, larger than red blood-corpuscles anc 
smaller than pus-corpuscles, are found in large numbers; these are tb (jj 
sarcoma corpuscles. They are not only found singly, scattered through 
out the field, but in variously sized, sometimes large groups. These cor.j 
puscles are so different in appearance from the larger, in these case) 
almost invariably pale pus-corpuscles, as to become noticeable at firs;! 
glance. Being the elements seen in the tumor, they will never appear ii 
any other disease. 

Besides these features, we find the evidences of a more or less sever 
inflammation, either with or without hemorrhage. In the case uncle / 
consideration, red blood-corpuscles were not numerous, but pus-corpus l' 
cles were present in fairly large numbers, many containing fat-globule* 
showing chronicity. These pus-corpuscles were almost without exceptio im.\, 
finely granular, and in some one or more nuclei were plainly visible, sho^ 
ing conclusively that the constitution was poor. Epithelia from th 
convoluted as well as the straight collecting tubules of the kidney, man Jlt '^ 
containing fat-globules, were present in large numbers, and groups C; 



fie. 



the 






sc 






IF 



•■ 



&y8 






c. 



© 







sc 



Fig. 117. — Sarcoma of Kidney, Chronic Catarrhal Pyelitis and Cystitis 

(X 500). 
RB, Red blood-corpuscles ; PC, pus-corpuscles; SC, sarcoma corpuscles ; CE, epithelia 
rom the convoluted tubules of the kidney; SE, epithelium from the straight collecting 
ubules of the kidney; UE, epithelia from the ureter; PE, epithelia from the pelvis of the 
ddney; MB, epithelia from the middle layers of the bladder; CT, connective-tissue 
hreds; FG, free fat-globules. 



DISEASES OF THE KIDNEY AND PELVIS. 247 

free fat-globules were also quite abundant. Epithelia from the pelvis of 
! the kidney could be seen, and in many of them the endogenous new-for- 
mations of pus-corpuscles, indicating pressure, were present. Epithelia 
from the ureter and the middle layers of the bladder completed the 
I features. 

Not infrequently a croupous nephritis may be present, and then casts, 
especially of the granular and fatty variety, will be found. 

CANCER. 

In cancer of the kidney, a positive diagnosis cannot be made so easily 
from the simple examination of the urine. When a large number of ir- 
regular connective-tissue shreds, containing inflammatory corpuscles, and 
perhaps also larger, coarsely granular, frequently multinucleated epithelia 
are found, together with all the evidences of a chronic inflammation, can- 
cer can undoubtedly be suspected, and the clinical symptoms will soon 
clear up the diagnosis. In rare cases we may find regular cancer nests, 
similar to those to be described in cancer of the bladder. 



CHAPTER XVII. 

DISEASES OF THE BLADDER. 
I. INFLAMMATIONS OF THE BLADDER. 

According to the degrees of intensity, inflammation of the bladder- 
cystitis — may be divided into catarrhal, suppurative, and ulcerative. 
The inflammation may be either acute, subacute, or chronic, and may af- 
fect either small portions of the mucous membrane of the bladder only, 
or almost the whole. 

The pathological changes in catarrhal inflammation of the bladder 
are the same as those found in any mucous membrane, and have beer 
described in the previous chapter. In severe inflammations ulcers may 
be formed, which may become quite extensive, and in rare cases even 
lead to perforation. Occasionally abscesses will form in the wall of the 
bladder. 

Causes. — The causes of a cystitis, which may be either primary or sec- 
ondary, are numerous. Primary cystitis may be due either to exposure 
to cold, to chemical irritation, or to traumata. That a simple exposure 
to cold may cause a cystitis, often quite severe in character, cannot be 
denied. Among the chemical irritants different remedial agents, such as 
turpentine, copaiba, cantharides, and strong mineral acids, may be men- 
tioned. Alcoholic stimulants in large amount may cause mild attacks, as 
well as certain articles of diet, such as asparagus. 

One of the most common causes of cystitis is the passage into the 
bladder of instruments, such as catheters or sounds, which have not been 
thoroughly disinfected, so that pyogenic bacteria are introduced in large 
numbers. Again, traumata of different kinds are often responsible for 
the development of a cystitis. 

Secondary cystitis is at least as frequent as the primary form, and is 
often due to an extension of the inflammatory process from one or other 
of the genito-urinary organs. Gonorrhoea is a common cause of cystitis, 
in the first days of the disease as well as later on. Prostatitis, hypertro- 
phy of the prostate gland, seminal vesiculitis, vaginitis, cervicitis, and 
parametritis, as well as perimetritis, may all cause it. Again, inflamma- 
tions of the bladder may be produced by an inflammation of the kidney, 

248 



DISEASES OF THE BLADDER. 249 

pelvis, and ureter, the process gradually extending downward. Indeed, 
it is rare that a secondary cystitis, though mild in character, does not 
accompany a nephritis or pyelo-nephritis, even in acute cases. In chronic 
cases, such an accompanying inflammation is always present. 

That other affections of the bladder, such as tumors or calculi in the 
bladder, will soon cause an inflammation, is evident. In many other dis- 
eases, such as the different infectious and contagious diseases, it may occur 
at any time. Retention of the urine must be looked upon as an important 
cause. 

In most cases, though not necessarily in all, micro-organisms in vary- 
ing numbers will be present. In the mild acute cases, they may be absent 
entirely, or be present in small numbers only, while in the more pro- 
nounced cases they are always numerous. As a rule, both cocci and ba- 
cilli are found, though one or the other may predominate or even exist 
alone. The varieties of the micro-organisms which may be present in the 
bladder cannot always be determined, since some of those seen when the 
urine is examined are undoubtedly of secondary origin. Among the 
cocci, the different staphylococci — staphylococcus pyogenes aureus, 
albus, and citreus — as well as the streptococci pyogenes are common. 
The micrococcus urese is often found in large numbers, and a variety 
of sarcina, called sarcina urinse, somewhat smaller than the usual form, 
is not rarely seen. 

Among the bacilli, the bacterium coli commune, the bacillus urese, 
and the urobacillus liquefaciens septicus, occur. In some cases lepto- 
thrix threads are abundant. It has been claimed that the bacterium coli 
commune is more frequently found in cystitis than any other one bacil- 
lus, though the number of bacilli described is quite large. 

In the cases of so-called bacteriuria, bacteria of various forms may be 
present in enormous numbers in the bladder, and their origin cannot 
always be determined. It is certain that bacteria alone will not cause 
cystitis, but when an irritation of some kind exists they can set up a se- 
vere inflammation. The reaction of the urine does not necessarily need 
to be alkaline when micro-organisms have developed; but on the con- 
trary, some, as the bacterium coli commune, are frequently found with 
an acid reaction. 

Clinical Symptoms. — The symptoms seen in cystitis vary considerably 
with the severity and acuteness of the attack. An intense acute inflam- 
mation may be ushered in by chills, followed by moderately high fever 
and all the concomitant symptoms of the same. In milder cases fever 
will not be present. Frequent micturition invariably exists; this varies 
considerably with the intensity of the inflammation, and in the severe 
cases there is a constant desire to urinate, although only a few drops may 



250 URINARY ANALYSIS AND DIAGNOSIS. 

be voided at a time. More or less intense pain is never absent. The pain 
may be most pronounced at or just before the beginning of micturition, 
be somewhat diminished during the flow of urine, and again become more 
severe at the end of micturition. At other times the flow of urine seems 
to increase the pain, which is diminished immediately after. A certain 
amount of pain or discomfort almost invariably exists irrespective of 
urination, and may radiate to the back, thighs, scrotum, and penis. It 
may be most severe in the perineum. Pressure upon the bladder, as well 
as the passage of a catheter or other instrument, always causes more 
suffering. 

In chronic cases which are comparatively mild in character, frequent 
micturition, sometimes not very pronounced, with a feeling of discom- 
fort, may be the only symptom. When a cystitis has lasted for a long 
time the bladder becomes enlarged, sometimes to a great degree. In such 
cases the bladder is never entirely emptied, and incontinence may exist, 
so that the urine will dribble away continually. 

Appearance of Urine. — The appearance of the urine varies. In the 
mild cases, when few or no bacteria are present, it may be perfectly trans- 
parent; but as soon as bacteria in moderate or large numbers have de- 
veloped, it is more or less turbid. The specific gravity also differs, being 
normal in mild cases and increased or diminished in the severer forms. 
Albumin is never entirely absent in these cases, since it will always be 
found whenever pus-corpuscles are seen in the urine. In mild cases, how- 
ever, no more than a trace, sometimes very faint, can be discovered, while 
in the more intense cases it may exist in large amount. The reaction of 
the urine may be acid or alkaline. In mild acute cystitis, even when a 
few bacteria are seen, it may be acid, though, as a rule, only slightly so. 
In chronic cases, on the other hand, the urine is always more or less alka- 
line, and the alkalinity may be marked. 

CATARRHAL CYSTITIS. 

Microscopical Features. — The microscopical features in cystitis differ 
in the acute and chronic cases, as well as with the intensity of the inflam- 
mation, and are always characteristic on account of the presence of blad- 
der epithelia. Pus-corpuscles, epithelia from the bladder, and mucus- 
threads are never absent, though their amount differs in the different 
cases. 

Acute Catarrhal Cystitis (Fig. 118). — In an acute catarrhal cystitis 
of moderate severity the reaction of the urine may still be slightly acid, 
and salts will usually be found under the microscope, though they are not 
abundant. Those most commonly seen are crystals of calcium oxalate of 




Fig. 118. — Acute Catarrhal Cystitis (X 500). 
RB, Red blood-corpuscles; PC, pus-corpuscles; 0, calcium oxalate; UA, ammonium 
urate ; UB, epithelia from the upper layers of the bladder; MB, epithelia from the middle 
layers of the bladder ; MT, mucus- threads; MC, mucus-corpuscles; CB, bacilli and cocci. 



DISEASES OF THE BLADDER. 253 

different sizes, present in almost every field. Even in those cases, how- 
ever, which still give an acid reaction, globules of ammonium urate, partly 
the dumb-bell form of ammonium urate in statu nascenti, partly small, 
but fully formed globules, are seen. 

Pus-corpuscles are never absent, as without them no diagnosis of in- 
flammation is possible; but their number varies, and the mildest cases 
show perhaps only two, three, or four in every field. The more intense 
the inflammation, the more numerous are the pus-corpuscles. Red blood- 
corpuscles are present in every case of acute cystitis, and also vary in 
number to a great degree, but, unless hemorrhages have occurred, are 
never abundant. In hemorrhages, which are rare in these acute cases 
and are usually found only when the cystitis is due to calculi, tumors, 
parasites, or a severe trauma, the red blood-corpuscles may be so abun- 
dant as to obscure the other features. 

The diagnosis of a cystitis depends entirely upon the presence of the 
characteristic epithelia from the different layers of the bladder. As pre- 
viously explained, the bladder has stratified epithelium, the different 
strata of which contain different epithelia. The upper layers are lined 
with flat, the middle with cuboidal, and the deepest covering, one layer 
only, with columnar epithelia. The flat epithelia are desquamated in per- 
fect health, though. to a small degree only, and when these are present 
alone in the urine, without any pus-corpuscles or cuboidal epithelia, the 
diagnosis of cystitis must never be made. As soon as the cuboidal epi- 
thelia are found, we can be certain of a pathological process in the blad- 
der; the more pronounced, the more numerous they are. 

In an acute catarrhal cystitis the flat epithelia from the upper layers 
and the cuboidal from the middle layers are always present together, and 
the more flat epithelia we find in comparison with the cuboidal, the milder 
the case. In such cases pus-corpuscles are scanty. When the flat and 
cuboidal epithelia are present in equal numbers, the inflammation is not 
very severe, but when the cuboidal epithelia are more abundant than the 
flat, pus-corpuscles will also be more numerous and the inflammation is 
more intense. We do not expect to find columnar epithelia, unless the 
inflammatory process has extended to the deepest layer, and has become 
very pronounced. 

The sizes of the different epithelia vary in a small degree only in the 
different cases, therefore can always be diagnosed. Care must be taken 
not to mistake folded epithelia from the upper layers for columnar epi- 
thelia, which they sometimes resemble; they are, however, somewhat 
more irregular, always paler, and more finely granular than those from 
the deepest layer. 

Mucus in the form of threads and corpuscles can be found in almost 



254 URINARY ANALYSIS AND DIAGNOSIS. 

every case, but is more abundant in the severer inflammations. Mucus- 
threads are pale, and consist of fine, sometimes hardly perceptible fibres. 
They should never be mistaken for connective-tissue shreds — which we 
do not expect to find unless the case is intense or hemorrhages occur — 
since they are pale, finely striated, and the individual fibres usually run 
quite parallel. When large, mucus-threads may branch off and some- 
times fill the greater part of the field. Besides the threads, mucus-cor- 
puscles are also found in varying numbers. Such corpuscles are pale, 
more or less irregular in outline, finely granular, and do not contain a 
nucleus. They may have the size of pus-corpuscles, but are often consid- 
erably larger. Even in the milder cases of cystitis the so-called cylin- 
droids or mucus-casts — pale, delicate, striated formations — can also be 
seen. 

The only other features which may be found in these cases are bac- 
teria. Their number has little significance as to the severity of the in- 
flammation, since even in severe inflammations they may be scanty, 
while they may be abundant in a mild case. 

Chronic Catarrhal Cystitis (Fig. 119). — In chronic catarrhal cystitis 
the reaction of the urine is usually alkaline, and the more pronounced 
this reaction, the more chronic is the case. The sediment generally con- 
tains the different varieties of phosphates, both complete and incomplete 
triple, as well as star-shaped simple phosphates. Globules of ammonium 
urate are often quite abundant. 

Pus-corpuscles vary in number according to the intensity of the in- 
flammation, and in many small, glistening fat-granules and -globules will 
be found. Sometimes they contain dark brown granules of pigment. In 
the more intense cases pus-corpuscles are numerous, and are frequently 
swollen, hydropic, or disintegrated. In purely chronic cases red blood- 
corpuscles are scanty or entirely absent. When acute exacerbations or 
hemorrhages ensue, they become considerably more numerous. 

Epithelia are always present in greater or less amount, but their rela- 
tive numbers are somewhat different from those found in acute cystitis. 
While in the latter flat epithelia from the upper layers are quite abundant, 
they are either entirely absent in the chronic cases, or are seen in small 
numbers only; this is one of the differential points of diagnosis. Epi- 
thelia from the upper layers, when present in large numbers, denote either 
an acute case or an acute exacerbation of a chronic inflammation. 
Cuboidal epithelia from the middle layers are always found in varying 
numbers, many containing fat-granules or -globules. Columnar epithelia 
from the deepest layer are seen in the severer cases only, and then in 
small numbers. Free fat-globules are always present. 

Mucus-threads and -corpuscles are constant features in chronic ca- 



MB 




Fig. 119. — Chronic Catarrhal Cystitis (X 500). 
UA, Ammonium urate; TP, triple phosphates; SP, simple phosphates; PC, pus- 
corpuscles ; MB, epithelia from the middle layers of the bladder, containing fat-globules ; 
MT, mucus-threads ; MC, mucus-corpuscles ; BC, bacilli and cocci ; FG, free fat-globules. 



DISEASES OF THE BLADDER. 257 

tarrhal cystitis. In cases having a highly alkaline reaction, the urine is 
ropy and a jelly-like, viscid mass is present, sometimes so pronounced as 
to compose the greater part of the sediment. A urine containing such 
masses always has an ammoniacal odor, and the alkaline salts are ex- 
tremely numerous. Besides the salts and bacteria, such a jelly-like mass 
consists of strings of mucus, sometimes filling entire fields of the micro- 
scope. In many of these cases neither pus-corpuscles nor epithelia can be 
recognized to any great degree, having become hydropic, pale, and ap- 
parently changed to mucus-corpuscles. The appearance of a urine con- 
taining such masses is so characteristic to the naked eye that a diagnosis 
of chronic cystitis can, in many cases, be made without a microscopical 
examination. Bacteria are never absent in chronic inflammations, and 
are usually abundant. 

Subacute Catarrhal Cystitis. — The features found in a subacute 
catarrhal cystitis are a moderate number of red blood-corpuscles, pus- 
corpuscles, as a rule not abundant, a few epithelia from the upper layers 
of the bladder, a moderate number from the middle layers, a few fat- 
globules, and a moderate amount of mucus. The reaction in such cases 
is usually slightly alkaline. 

ULCERATIVE CYSTITIS. 

The development of ulcers in the bladder is not rare, and traumata of 
different kinds are perhaps the most frequent causes. With the presence 
of calculi and parasites in the bladder, but especially in tuberculosis in 
any part of the genito-urinary tract, ulcerative cystitis is of common oc- 
currence. In pronounced cases such a urine has an intensely putrescent 
odor and is very turbid. 

Microscopical Features. — Acute Ulcerative Cystitis (Fig. 120). — Un- 
der the microscope the features of an acute ulcerative cystitis are the 
following: 

The number of pus-corpuscles varies considerably, and they are not 
necessarily abundant. Red blood-corpuscles are always fairly numerous, 
and in many cases even hemorrhages exist. Epithelia from the bladder 
are abundant, and present from all three layers; the columnar epithelia 
from the deepest layer, usually absent in catarrhal inflammation, are 
often almost as abundant as those from the middle layers. 

Connective-tissue shreds are found in large numbers, some of the 
shreds being large, while others are only of small size. These shreds are 
of moderate refraction, and consist of wavy, irregular fibres. The differ- 
ence between them and mucus-threads, which are also present in varying 
numbers and are much paler than the former, is plain. 

Bacteria are numerous in all these cases, and zooglcea-masses are in- 
17 



258 URINARY ANALYSIS AND DIAGNOSIS. 

variably found. These masses are often large and numerous, and are 
never seen to such an extent in simple catarrhal cystitis. Their diagnosis 
is easy, and when large groups are present around connective-tissue 
shreds, in fresh urine, the existence of an ulcer is almost certain. The 
salts vary considerably in amount in acute cases, and at times they are 
found in small numbers only. 

Chronic Ulcerative Cystitis (Fig. 121). — Alkaline salts, especially 
phosphates, are abundant. Pus-corpuscles are present in moderate num- 
ber, but red blood-corpuscles are usually scanty. Epithelia from the 
upper layers of the bladder are either entirely absent or scanty, though 
transitional epithelia may be found. Cuboidal and columnar epithelia 
are abundant, the latter being often almost as numerous as the former, 
Fat-globules and -granules, both in free groups and in the pus-corpuscles 
and epithelia, are always seen. Connective-tissue shreds are just as abun- 
dant as in acute cases, while mucus-threads and -corpuscles are more 
numerous. Zooglcea-masses are never absent, and may attain large sizes 
Other bacteria are also found in large numbers. 

When the diagnosis of a chronic ulcerative cystitis has become cleai 
from the above features, and the constitution is greatly impaired, as seer 
by the finely granular pus-corpuscles; when, furthermore, no evidence* 
of calculi or parasites are found, an examination for tubercle bacill 
should always be made. In a number of cases, where the clinical symp 
toms were vague, but an ulcerative cystitis was present, examination fo:< 
tubercle bacilli revealed the existence of a tuberculosis in the urinar 
tract, and at once cleared up the case. 

In one case, which was examined by the author, the ulcerative cystiti 
was produced by actinomyces. The urine contained a number of smal 
granular masses, apparent to the naked eye, and upon examination the& 
were found to consist of the characteristic club-shaped conglomeration 
of actinomyces, previously described. 

SUPPURATIVE CYSTITIS. 

Suppurative cystitis is comparatively rare. The diagnosis can b 1 
made if pus-corpuscles are numerous and epithelia from the differen 
layers of the bladder abundant. Connective-tissue shreds are alway 
present and red blood-corpuscles quite numerous. In such cases bacteri 
will be seen in larger numbers, but the zoogloea-masses, which are foun 
in every case of ulcerative cystitis, are not present, or, if so, not pnij 
nounced. The differential diagnosis between an abscess and an ulce 
must, however, be made chiefly from the comparative numbers of pu? 
corpuscles, which in an abscess are considerably more abundant. 



MB 




Fig. 120. — Acute Ulcerative Cystitis (X 500). 
RB, Red blood-corpuscles ; PC, pus-corpuscles ; UB, epithelia from the upper layers of 
he bladder; MB, epithelia from the middle layers of the bladder; DB, epithelia from the 
,eepest layer of the bladder; CT, connective-tissue shreds; MT, mucus-threads; Z, 
oogloea-masses ; ZC, connective-tissue shreds with zooglcea-masses ; M, micrococci; 
it, streptococci ; B, bacilli. 



MT 




Fig. 121. — Chronic Ulcerative Cystitis (X 500). 
PC, Pus-corpuscles, some containing fat-globules; MB, epithelia from the middle 
yers of the bladder, some containing fat-globules ; DB, epithelia from the deepest layer 
: the bladder; TP, incomplete triple phosphate; CT, connective-tissue shreds; MT, 
Lucus-thread ; FG, free fat-globules; Z, zoogloea-mass ; BC, bacilli and cocci; ZC, 
xigloea-masses with connective-tissue shreds. 



DISEASES OF THE BLADDER. 263 



PERICYSTITIS. 

When an inflammation is present around the bladder, instead of in the 
wall of the bladder proper, and pressure is exerted upon that organ, the 
epithelia from the middle layers of the bladder may show changes in a 
pronounced degree, which have been previously alluded to as endogenous 
new-formations. Such changes will occur when parametritic exudates 
exist, pressing upon the bladder, when a tumor is present either in the 
neighborhood of the bladder or in the wall of the bladder, or even simple 
extravasations of blood in the wall of the bladder may cause them. 
Pressure of any kind, no matter how slight, if continued for some time, 
such as pressure of trie uterus upon the bladder, or of the prostate gland 
on account of hypertrophy of that organ, or inflammations of the seminal 
vesicles, will all produce such changes. 

In simple catarrhal cystitis a small number of epithelia from the mid- 
dle layers may be found, containing a number of nuclei or even newly 
formed pus-corpuscles. So long as these formations are scanty, they may 
be produced by the inflammatory process alone — a fact which has been 
known for many years. As soon, however, as the epithelia become irri- 
tated through pressure of some kind, the endogenous new-formation of 
pus-corpuscles in the desquamated cuboidal or columnar epithelia is very 
abundant. One epithelium may contain from two to four or even six 
such pus-corpuscles, or, instead of them, vacuoles may be seen, or pus- 
corpuscles and vacuoles in varying numbers. 

The features found in a case of pericystitis due to a parametritis are 
shown in Fig. 122. They are the following: 

Pus-corpuscles are present in rather large numbers, and red blood- 
corpuscles are fairly numerous. Cuboidal epithelia from the middle layers 
of the bladder are abundant, and in almost every one the endogenous 
new-formation is plainly visible; smaller cuboidal epithelia from the ure- 
ters are present in moderate numbers, some of which also contain endog- 
enous new-formations. In a few of the pus-corpuscles and epithelia fat- 
globules are seen, and small groups of free fat-globules are also found. 
Mucus-threads are abundant and large, while connective-tissue shreds 
are scanty and small. 

Besides these features, ciliated columnar epithelia from the mucosa of 
the uterus and larger irregular epithelia from the cervix uteri are seen, as 
well as those from the upper and middle layers of the vagina, which, with 
the pus-corpuscles, are sufficient evidences of an endometritis, cervicitis, 
and vaginitis. 



264 URINARY ANALYSIS AND DIAGNOSIS. 



II. TUMORS OF THE BLADDER. 

Although many different varieties of tumors may occur in the bladder, 
the most common, and those which can frequently be diagnosed from an 
examination of the urine, are benign papilloma and malignant sarcoma 
and cancer. Myoma is a rare tumor in the bladder, but when present can 
also be diagnosed, if particles of the tumor appear in the urine. As long 
as no ulceration has taken place, the presence of a tumor of any kind can 
only be suspected; but as soon as ulceration has set in and particles of 
the tumor are found in the urinary sediment, the diagnosis becomes 
positive. 

Clinical Symptoms.— In all tumors of the bladder, benign as well as 
malignant, one of the first, if not the first, and most pronounced symp- 
toms is hsematuria, mild in character only at the commencement, and 
occurring at long intervals, but later becoming more pronounced and 
more frequent. This hsematuria may take place at any time, and is just 
as common during rest as when the patient is active. Besides the hsema- 
turia, pain is present in many cases, but not in all, being more frequent 
in malignant than in benign tumors, and radiating to the perineum, the 
thighs, and the scrotum. In benign growths, pain, if present at all, is 
rarely pronounced. Frequent micturition may exist quite early in the 
disease, and becomes more pronounced in the later stages. 

Malignant tumors sooner or later will cause general symptoms, and, 
as a rule, end fatally in the course of one or two years, although cases of 
undoubted sarcomata have been known to last four or five years. 

None of the symptoms here given are at all characteristic, and micro- 
scopical examination of the urine must be relied upon for a positive diag- 
nosis. Tumors of the bladder may occur at all ages, a case of papilloma 
having been diagnosed by the author from the urine of a child of one year. 

PAPILLOMA. 

Microscopical Features. — The microscopical features in a case of papil- 
loma of the bladder are illustrated in Fig. 123. 

Since hemorrhage is of such common occurrence in these tumors, red 
blood-corpuscles are usually present in the urinary sediment in large 
numbers. These may be irregularly scattered throughout the field, or 
are found conglomerated in groups, partly yellowish, containing hsemo- 
globin, but at the time of examination mostly colorless, with the charac- 
teristic double contours. In cases of active hemorrhages, hsematoblasts, 
having the appearance of red blood-corpuscles, but only half their size, 




Fig. 122. — Pericystitis, Due to Parametritis (X 500). 
RB, Red blood-corpuscle : PC, pus-corpuscles ; UB, epithelium from the upper layers 
31 the bladder; MB, epithelia from the middle layers of the bladder, with endogenous 
aew-f ormations ; UE, epithelia from the ureter, with endogenous new-formations; MU, 
epithelia from the mucosa uteri; CE, epithelia from the cervix uteri; UV, epithelia from 
the upper layers of the vagina; MV, epithelia from the middle layers of the vagina; 
M T, mucus-thread; MC, mucus-cast ; CT, connective-tissue shred ; FG, free fat-globules. 



it 



DISEASES OF THE BLADDER. 267 

may be abundant, If the latter contain haemoglobin, so that the double 
contour is not seen, care must be exercised not to mistake them for fat- 
globules, or even conidia; they may be found in large groups as well as 
singly, between the regular-sized blood-corpuscles. 

The characteristic features of a papilloma are peculiar connective- 
tissue shreds, which, as a rule, are abundant. Although variously sized 
shreds, not differing in any respect from those generally seen in the urine, 
are present, the larger numbers have an entirely different appearance. 
They are long, or extremely irregular, frequently branching in different 
directions, and often assume the shape of coils or knobs. Such shreds are 
coarsely granular, and not infrequently contain a number of inflammatory 
corpuscles. Again, they may be found studded with fat-globules of differ- 
ent sizes, some of these being quite large. In rare cases, blood-vessels, 
either in process of formation or fully formed, some of considerable size, 
may be contained in them. 

The forms in which connective-tissue shreds may be found in the urine 
when a papilloma exists are sometimes so peculiar that a diagnosis can 
only be made when smaller and more regular shreds are found. In one 
case it seemed at first glance as if large parasites of an unknown nature 
were present, but a more careful examination showed large knobs and 
coils, in which capillary blood-vessels, filled with blood-corpuscles, were 
seen coursing in various directions. The individual fibres of such shreds 
may have entirely disappeared, and the whole shred appears as a mass of 
coarsely granular protoplasm; these shreds might well be termed proto- 
plasmic outgrowths of connective tissue. The more common varieties of 
connective-tissue shreds found in papilloma are shown in the illustration. 

In all cases of papilloma, epithelia from the different layers of the blad- 
der, more especially the cuboidal and columnar varieties, are quite abun- 
dant, and usually are more or less studded with fat-globules, which latter 
are also seen in small groups. Many of the bladder epithelia contain the 
endogenous new-formations. Besides these, irregular, coarsely granular 
epithelia, with endogenous new-formations — the covering epithelia of the 
papilloma — are also present, These have the size of bladder epithelia, 
though they are always irregular, and are not characteristic of the papil- 
loma. In none of the cases were the epithelia found adherent to the con- 
nective-tissue shreds, and care must be taken not to attempt a diagnosis 
of a tumor from these epithelia alone. 

In every case of papilloma pus-corpuscles are present. They vary in 
amount with the intensity of the accompanying inflammation, which, 
though never absent, differs in degree in different cases. As a rule, the 
pus-corpuscles have a moderately coarse granulation, if the tumor has 
remained local and produced no secondary nephritis, showing that the 



268 URINARY ANALYSIS AND DIAGNOSIS. 

constitution of the patient is fairly good. In rare cases enormous masses 
of fibrin are found in the urine — regular fibrinuria. Mucus-threads are 
always present, though the other features may render them indistinct. 

SARCOMA. 

As has been described in the previous chapter, a sarcoma can be diag- 
nosed from the urine, when present in any part of the genito-urinary 
tract. Sarcomata of the bladder, although not common, undoubtedly 
occur. As in all tumors of the bladder, hemorrhages are frequent in sar- 
coma, and when the urine is examined during an attack of hemorrhage, 
the diagnosis becomes more difficult, since no such characteristic connec- 
tive-tissue shreds as in papilloma are here found. 

Microscopical Features. — If blood-corpuscles are present in moderate 
numbers only at the time of the examination, the other features are dis- 
tinct enough, and groups of small, glistening, frequently homogeneous, 
non-nucleated corpuscles, larger than red blood-corpuscles, but smaller 
than pus-corpuscles, are found in large numbers. These corpuscles, re- 
sembling lymph-corpuscles, are the elements characteristic of a small 
round-celled or lympho-sarcoma. Connective-tissue shreds must, how- 
ever, always be seen before the diagnosis becomes positive; these shreds 
may attain large sizes, and frequently contain inflammatory corpuscles. 
In most cases they do not differ from the shreds commonly found in urine, 
except by their large size. 

The other features seen in a sarcoma of the bladder are the same as 
those seen in every severe subacute or chronic catarrhal or ulcerative cys- 
titis, epithelia from the deepest layer of the bladder being rarely absent. 
Many epithelia contain endogenous new-formations, and these are not in- 
frequently seen in the accompanying epithelia from the ureters. Pus- 
corpuscles and fat-globules in varying numbers, together with mucus- 
threads, complete the features in these cases. 

CARCINOMA. 

The varieties of cancer developing in the bladder are principally the*) 
villous, the epithelial, and the medullary, the first two being more com- 
mon than the third. Villous or papillary cancer, the so-called cauliflower 
growth, is probably due in many cases to a secondary malignant change 
of a previously benign papilloma. This can be proved in those cases in 
which a tumor, having lasted for years and having always given the char- 
acteristics and features of a benign papilloma, becomes changed and as- 
sumes the features of malignancy. Such a villous cancer is in reality only 



PCT 




Fig. 123. — Hemorrhage from the Bladder, Due to Papilloma 
of Bladder (X 500). 
RB, Red blood-corpuscles ; H, haematoblasts; PC, pus-corpuscles; M B, epithelia from 
the middle layers of the bladder, containing fat-globules; DB, epithelia from the deepest 
layer of the bladder; PE, covering epithelia of papilloma; UB, epithelium from the upper 
layers of the bladder; PCT, connective-tissue shreds from papilloma; CT, connective- 
tissue shred; FG, free fat-globules. 



DISEASES OF THE BLADDER. 271 

a subvariety of an epithelial cancer or epithelioma, but seems to be more 
frequently seen in the bladder than the regular epithelioma. Medullary 
cancer, perhaps the most malignant, that is, most rapidly fatal of all can- 
cers, does not often develop in the bladder, and if it does, can hardly be 
distinguished by an examination of the urine, unless large masses of the 
tumor are cast off. 

Microscopical Features. — The features found in a urinary sediment of 
a case of villous cancer are depicted in Fig. 124. 

At the time this urine was examined, there was no active hemorrhage; 
therefore red blood-corpuscles were not numerous, though some were 
present. In different fields variously sized, dark brown or even black 
blood-clots were seen, composed of masses of. disintegrated blood-cor- 
puscles. Hsematoidin crystals, in the form of small plates and needles, 
the latter also seen in small conglomerations, were present, though not 
abundant. 

The connective-tissue shreds found in villous cancer may be even 
larger and more irregular than those seen in papilloma, not infrequently 
having the appearance of cauliflower-like excrescences, or containing 
large bulbs or knobs. These shreds are always coarsely granular and 
filled to a greater or less degree with inflammatory corpuscles, more pro- 
nounced than in papilloma. Again, a number of these shreds contain 
large, irregular cancer epithelia, sometimes even small nests, a feature 
never found in the connective tissue from a papilloma. Capillary blood- 
vessels, filled with blood-corpuscles, are sometimes found in these shreds, 
and may pervade their entire length. 

The original fibrous structure of the connective-tissue shreds has be- 
come changed, and only scanty fibres are present, the shred frequently 
appearing as a mass of coarsely granular protoplasm. Connective-tissue 
masses with a pronounced epithelial covering may perhaps occur in the 
urine in rare cases, but the detached masses from the tumor are usually 
changed, being broken down more or less completely, so that an epithe- 
lial covering is rarely seen. 

Besides the epithelia from the middle and deepest layers of the blad- 
der, containing fat-globules and endogenous new-formations, large num- 
bers of irregular, coarsely granular epithelia, partly single, partly in 
groups, are present; these also contain fat-globules and endogenous new- 
formations, and are the cancer epithelia. As long as these epithelia are 
seen alone, without other evidences of cancer, no diagnosis of a malignant 
tumor can be made, since they cannot be differentiated from other epi- 
thelia, as, for instance, those found in papilloma. In pronounced cases 
of cancer, however, variously sized epithelial nests may be seen, contain- 
ing three, four, or more cancer epithelia, and as soon as these are found 



272 URINARY ANALYSIS AND DIAGNOSIS. 

the diagnosis of a cancer becomes positive, even though the connective- 
tissue shreds should not be as characteristic as above described. Pus- 
corpuscles are always present in moderate or large numbers. 

Not only can a villous cancer be diagnosed, as just described, put also 
a regular epithelioma. In such cases the urine may contain epithelial 
masses showing a pronounced concentric arrangement, and even the fatty 
degeneration of the epithelia in the centre, producing shining, irregular 
masses of fat — the so-called cancer pearls — may be present. All the other 
features remain the same. 

The positive diagnosis of medullary cancer from the examination of 
urine is not so easy, though the presence of a cancer of some kind can, as 
a rule, be made from features similar to those described. 

When a tumor in the bladder has existed for some time, secondary 
inflammations of the ureter, the pelves of the kidneys, and the kidneys 
frequently develop sooner or later, and may become pronounced. In the 
kidney both catarrhal or interstitial and croupous or parenchymatous in- 
flammation may appear. The urine then shows all the features of such 
an inflammation, in addition to those of the tumor. In the case of a child 
one year of age, in which a papilloma of the bladder existed, all the feat- 
ures of a subacute croupous nephritis were also found, and the case proved 
fatal in a short time. 



III. PARASITES IN THE BLADDER. 

That a large number of micro-organisms of different kinds may not I 
infrequently be found in the bladder, has already been mentioned. 
Symptoms of a more or less pronounced cystitis will sooner or later ap- 
pear in almost all those cases. 

Animal parasites are also occasionally found in the bladder, among 
these being echinococci, actinomyces , distoma hamiatobium, and filaria san- 
guinis, as well as ascaris lumbricoides, strongylus gigas, and oxyuris ver- 
micularis. The diagnosis of these parasites is possible only when either 
their ova or the parasites themselves can be discovered in the urine. 
Many of these will invade the bladder only secondarily, being present in 
other organs, as the kidney or pelvis, or find their way into the bladder 
through the urethra. 

In every case of this kind, either hemorrhage or inflammations of 
var}dng degrees of intensity will sooner or later develop, with all the char- 
acteristic features in the urine. Ulcers are often due to such parasites, 
as, for instance, in the case of actinomycosis of the bladder previously 
mentioned. 










Fig. 124. — Villous Cancer of the Bladder (X 500). 
RB, Red blood-corpuscles; PC, pus-corpuscles; UB, epithelia from the upper layers of 
the bladder; MB, epithelia from the middle layers of the bladder, containing fat-globules 
land endogenous new-formations; DB, epithelia from the deepest layer of the bladder; 
CE, cancer epithelia; CN, cancer nests; CT, connective-tissue shreds; H, hsematoidin 
crystals; BC, blood-clot; FG, free fat-globules. 






CHAPTER XVIII. 

DISEASES OF THE SEXUAL ORGANS. 



Diagnosis of diseases of the sexual organs by microscopical examina- 
tion of the urine must of necessity be limited; it is not of so great prac- 
tical importance as in diseases of the urinary organs, since the clinical 
symptoms are in many cases sufficiently clear. There are, however, cases 
vhere the examination of the urine will either corroborate a suspected 
liagnosis or may even lead to the clearing up of the case when the clinical 
symptoms are not plain. This will naturally be of more common occur- 
rence in diseases of the male than of the female tract, in which latter, 
examination of the patient is, as a rule, sufficient for the diagnosis. 

In the male, inflammations of the urethra, the prostate gland, and the 
seminal vesicles can be diagnosed from urine examination, while in the 
female those of the vagina are easily diagnosed, and sometimes also those 
}f the cervix of the uterus and the uterine mucosa. 

URETHRITIS 

Acute Urethritis. — The clinical symptoms of an acute urethritis, 
whether gonorrhceal or non-gonorrhceal, are so evident that an examina- 
tion of the urine is never required to clear up the case. When the urine 
is examined for other purposes at the time such a urethritis is present, 
arge numbers of urethral epithelia are always found. In the first days of 
i urethritis the irregular, flat epithelia from the upper layers are more 
abundant, but soon the cuboidal and columnar epithelia are seen. Pus- 
corpuscles are present to a varying degree in every case. 

Chronic Urethritis. — The symptoms of a chronic urethritis, espe- 
cially when of a mild character, may be so slight that an examination of 
:he urine will help to clear up the diagnosis. 

In many or these cases conglomerations of mucus with pus-corpuscles 
ind epithelia — the so-called gleet-threads — are found, even though they 
ire scanty. Under the microscope these threads (Fig. 57) consist of a 
r arying amount of mucus, both fibres and corpuscles, from the mucous 
;lands of the urethra; pus-corpuscles, which are abundant in the more 
Pronounced, but may be quite scanty in the mild cases, and urethral epi- 



276 URINARY ANALYSIS AND DIAGNOSIS. 



. 



thelia, which also vary in number. Besides these features, epithelia from 
the prostate gland are almost invariably present, and are usually more 
numerous than the urethral, which latter may at times not be found at 
all. The larger numbers of pus-corpuscles and epithelia are seen studded 
with small fat-globules, and these may also be seen upon and between 
the mucus- threads. If gleet- threads are not present, irregular urethral 
epithelia in small numbers, with pus-corpusles, mucus-strings, and 
prostatic epithelia, are seen in many cases of chronic urethritis. 

When an ulceration or stricture exists in the urethra, the urine, as a 
rule, shows some features. In an ulceration, red blood-corpuscles in at 
least moderate numbers, pus-corpuscles, bacteria — especially the zooglcea- 
masses — urethral epithelia, mostly the cuboidal and columnar varieties 
together, and connective-tissue shreds are never absent. As the prostate 
gland almost invariably becomes involved in these cases, prostatic epithe- 
lia are also present. 

In stricture of a mild character, small connective-tissue shreds, with 
a few epithelia from the urethra and prostate gland, and a few pus-cor- 
puscles, are not infrequently seen, although there may be no features 
whatever in the urine of such cases. The urethral epithelia may have two 
or even more nuclei. 

PROSTATITIS. 

The diagnosis of a prostatitis from the urine is undoubtedly of greatei 
importance than that of a urethritis, since, especially in the mild chronic 
cases, the clinical symptoms may not be sufficiently pronounced. 

Causes. — The causes of a prostatitis are numerous, though probabl) 
the most frequent cause of an acute inflammation is an acute urethritis 
The passage of unclean instruments, such as sounds or catheters, injec- 
tions of chemical agents, or any irritant or injury of whatever kind, sucl 
as may be due to horseback or bicycle riding, may cause a prostatitis, as; 
well as simple exposure to cold and wet. In the course of febrile disease 
it also develops occasionally. 

Chronic prostatitis may be produced by stricture of the urethra, mas 
turbation, excesses in venery, hemorrhoids, constipation, or by inflamma 
tions of the neighboring organs. 

Clinical Symptoms. — An acute prostatitis, if severe, may be ushered 
in by chills and fever, followed by discomfort or pain in the perineal re 
gion and frequent micturition. The pain is usually increased upon mo 
tion, and the perineum is found to be sensitive upon pressure. 

In chronic prostatitis the symptoms may be slight, the principal on 
perhaps being the occasional discharge of a small amount of a clear, visci 
fluid, constituting the so-called prostatorrhoea; this flow is usually ir 



DISEASES OF THE SEXUAL ORGANS. 277 

creased upon defecation. Besides this, slight discomfort and tenderness 
in the perineum, frequent micturition, and slight pain at the end of urina- 
tion may be present. Enlargement of the gland may cause more or less 
retention of urine. 

Features Found in Urine. — The appearance of the urine varies con- 
siderably with the intensity of the inflammation, and is not characteris- 
tic. In acute cases slight or more pronounced hemorrhages may take 
place, and cause the urine to assume a darker color ; when considerable pus 
is present it will be more or less turbid, and also contain a varying amount 
of albumin. In mild chronic cases the urine may be perfectly clear. 

When such a urine is examined for albumin, it must not be forgotten 
that whenever pus-corpuscles and red blood-corpuscles are present albu- 
min will always be found, its amount depending upon the amount of pus 
and blood, so that in cases of abscesses or hemorrhages the urine may con- 
tain considerable albumin, and faint traces are rarely absent when there 
is any inflammation of the prostate gland. It is evident, therefore, how 
important a microscopical examination of the urine becomes in all these 
cases, since such an examination alone will determine whether the kid- 
neys are inflamed, and this be the source of albumin, or whether the albu- 
min is due simply to the prostatitis. 

Acute Prostatitis. — In an acute prostatitis of moderate severity, the 
features found in the urinary sediment are red blood-corpuscles in vary- 
ing numbers, pus-corpuscles, mucus, and epithelia from the prostate 
s^land. Red blood-corpuscles are never absent in an acute inflammation, 
and are numerous when hemorrhages occur, as is sometimes the case. 
Pus-corpuscles vary in number according to the degree of intensity of the 
inflammation. Mucus, in the form of threads and corpuscles, is always 
increased, and may be present in large amount. 

The characteristic features of a prostatitis are the epithelia. The 
prostate gland is, as a rule, lined by simple cuboidal epithelium, though 
Dccasionally a pseudo-stratified epithelium, partly cuboidal and partly 
columnar, is seen; while the ducts of the gland are lined by columnar 
spithelia. The cuboidal epithelia are about twice the diameter of the pus- 
corpuscles, and are larger than those from the convoluted tubules of the 
kidney. They have the same size as the cuboidal epithelia from the ure- 
ters, and when they are present alone, without the columnar epithelia 
from the ducts, the comparative number of these, with those of the kid- 
ney and pelvis of the kidney, must be taken into consideration. An in- 
flammation of the ureters is almost invariably secondary to a nephritis 
3r pyelitis, and when the epithelia from the kidney or pelvis, or both, are 
seen, together with a small number of those twice the size of the pus- 
corpuscles, they are always ureteral. The absence of symptoms of a 



278 URINARY ANALYSIS AND DIAGNOSIS. 

pyelo-nephritis, but the presence of a varying number of cuboidal epi- 
thelia double the size of pus-corpuscles, would show that they are from 
the prostate gland. Since a prostatitis, especially when it has lasted for 
some time, may cause a secondary inflammation of the bladder, the ure- 
ters, pelvis of the kidney, and kidney, epithelia from all these organs may 
be present, and here not only the comparative number, but also the clin- 
ical symptoms of the case, will have to be taken into consideration to 
determine the positive source of the epithelia. 

On the other hand, in an inflammation of the prostate gland the col- 
umnar epithelia from the ducts of the gland are almost invariably pres- 
ent with the cuboidal epithelia in moderate or even large numbers, while 
the columnar epithelia from the ureters are rarely seen 7 and then in small 
numbers only. The columnar epithelia from the pelvis of the kidney, 
although they vary in size to a certain degree, are always somewhat larger 
than those from the ducts of the prostate gland and more irregular, so 
they cannot be mistaken for the latter. 

A prostatitis is in most cases associated with inflammation either of 
the urethra or of the bladder (especially the neck), or both, and the epi-, 
thelia from these organs will then be associated with those from the pros- 
tate gland. Severe cases, as already mentioned, are ascending in charac- 
ter, producing a pyelitis and finally a nephritis, with all the accompanying 
features of the same. 

Acute suppurative prostatitis, or abscess of the prostate gland, is of 
common occurrence, and its features are illustrated in Fig. 125. 

We see here red blood-corpuscles in moderate numbers, and pus-cor- 
puscles in extremely large amount, which not infrequently fill up entire 
fields of the microscope. Cuboidal epithelia from the prostate gland, as 
well as columnar epithelia from the ducts, are always present in these 
cases, and are not infrequently found in groups. Connective-tissue shreds 
are seen in varying numbers, and unless they are found the diagnosis of 
an abscess must never be made, even if pus-corpuscles and epithelia are 
numerous. The latter is the chief point of distinction between a severe, 
but non-suppurative, prostatitis and an acute abscess. Mucus- threads 
may be found in large numbers. 

When a suppurative prostatitis is the result of a urethritis, which is 
frequently the case, the irregular epithelia from the urethra will be found 
accompanying the features just described, and, as a rule, epithelia from 
the upper and middle layers of the bladder are also present, showing a 
cystitis. In both the urethral epithelia and the bladder epithelia an en- 
dogenous new-formation of pus-corpuscles may be seen. 

Chronic Prostatitis. — Chronic prostatitis will give characteristic feat- 
ures under the microscope (Fig. 126). 



PC 




m 



DP 



CT 



MB 




9 VMJ 



, m§0§m 



^ :^^ 



IRwws 




PE 







MT 



HB 



Fig. 125. — Acttte Abscess of the Prostate Gland (X 500). 
RB, Red blood-corpuscles; PC, pus-corpuscles; PE, epithelia from the prostate gland; 
DP, epithelia from the ducts of the prostate gland; UE, epithelia from the urethra; 
CT, connective-tissue shreds; MT, mucus-threads; MB, epithelia from the middle layers 
of the bladder. 




Fig. 126. — Chroxic Prostatitis (X 500.) 
PC, Pus-corpuscles containing fat-globules; PE. epithelia from the prostate gland, 
containing fat-globules; DP, epithelia from the ducts of the prostate gland, containing 
fat-globules ; MB, epithelia from the middle layers of the bladder; NB, epithelia from the 
neck of the bladder; MT, mucus-threads; FG, free fat-globules. 



DISEASES OF THE SEXUAL ORGANS. 283 

Red blood-corpuscles are here either entirely absent or scanty, and 
pus-corpuscles are present in moderate numbers only. Cuboidal as well 
as columnar epithelia from the prostate gland and its ducts are quite abun- 
dant, the former being often found in groups of four, five, or more. Both 
the pus-corpuscles and the epithelia are studded with glistening fat-glob- 
ules and -granules, which latter also lie free. In the case from which the 
illustration was drawn, this fatty change was extremely pronounced — 
more so than is usually the case. Every epithelium and almost every 
pus-corpuscle were filled with these globules, giving the whole corpuscle 
a glistening appearance. The free groups of fat-globules were numerous 
and large, the individual globules in many groups being of considerable 
size. Mucus-threads were seen in moderate numbers, but connective- 
tissue shreds were absent. 

In this case no urethral epithelia were seen, but the accompanying 
cystitis was pronounced, so that the epithelia from the bladder were quite 
abundant. Not only the regular cuboidal epithelia from the middle layers 
of the bladder, studded with fat-globules, were present, but also larger 
epithelia from the neck of the bladder. Mention should here be made of 
the fact that the epithelia from the neck of the bladder are usually larger 
than those found in the other portions of the bladder, and may even at- 
tain the size of vaginal epithelia. These large epithelia are. however, 
never numerous, are seen only with the other features, and are not studded 
with bacteria, as is almost invariably the case- in the epithelia from the 
upper layers of the vagina. 

Hypertrophy of the prostate gland may give characteristic features in 
the urine, even before the clinical symptoms are sufficiently pronounced 
to lead to a suspicion of the affection (Fig. 127). In all these cases the 
features of a chronic prostatitis are found, usually with a small or moder- 
ate number of pus-corpuscles only, but with small connective-tissue 
shreds, which in many cases are scanty. If the latter are seen with all the 
evidences of a chronic prostatitis, especially when the age of the patient 
is above forty or forty-five years, the diagnosis of hypertrophy can be 
made. When the hypertrophy becomes more pronounced, endogenous 
new-formations will be seen in the larger numbers of epithelia from the 
middle layers of the bladder, as well as in those from the urethra and even 
in a number from the prostate gland and ducts. In these cases prostatic 
concretions, previously described, are not rarely found. 

Tuberculosis. — Tuberculosis of the prostate gland is probably never 
present alone without an involvement of the neighboring organs, and is a 
comparatively rare affection. It will always give the symptoms of a pros- 
tatitis or an abscess of the prostate gland with a considerably impaired 
constitution, as shown by the pale, finely granular pus-corpuscles. When 



284 URINARY ANALYSIS AND DIAGNOSIS. 

it is suspected, repeated examinations for tubercle bacilli must be 
made. 

Tumors. — Tumors of the prostate gland are not of rare occurrence, 
and both sarcoma and cancer are met with, and can be diagnosed from 
the urine. In sarcoma, the characteristic small, glistening bodies previ- 
ously described, with large connective-tissue shreds, and the evidences of 
a chronic prostatitis are seen; while in cancer the connective-tissue shreds 
and epithelia, described in cancer of the bladder, may be found in the 
urine. The clinical symptoms must of necessity help the microscopical 
examination in many of these cases. In some cases neither sarcoma cor- 
puscles nor cancer epithelia can be found, but all the evidences of a pro- 
nounced hypertrophy of the prostate are seen in urine, together with 
large connective-tissue shreds, which of themselves are sufficient cause of 
suspicion of the presence of a tumor. 

SPERMATORRHOEA. 

Spermatorrhoea, which in young men is by no means rare, and con- 
sists in an occasional involuntary flow of semen, especially at the end of 
defecation, or even upon urination, cannot infrequently be diagnosed 
from the urine. 

When a urine is to be examined to prove the presence of a spermator- 
rhoea, it is best to take either the first urine voided in the morning or the 
last quantity voided during defecation. In such a urine the elements of 
the sperma, with spermatozoa in large numbers, will be found. In almost 
all these cases a prostatitis of varying degrees of intensity will exist and 
give the features under the microscope. 

Whenever a prostatitis is found in young men in whom no other cause 
can be discovered, a suspicion of spermatorrhoea must arise, even when 
no spermatozoa are seen in the urine first examined. Repeated examina- 
tions will invariably show these, and render the diagnosis positive. The 
clinical symptoms of a chronic prostatitis — that is, an occasional discharge 
of a clear, viscid fluid, especially in younger men — may not infrequently 
lead to the mistaken diagnosis of spermatorrhoea, which disease must 
never be diagnosed without the evidence of a discharge of sperma. 

Besides the prostatic epithelia, those from the seminal vesicles and 
ejaculatory ducts may also be seen in the urine. Mucus is always present 
in these cases in large amount, and mucus-casts or cylindroids may be 
abundant. Care must be taken not to mistake these for true hyaline 
casts from the uriniferous tubules of the kidney, which they sometimes 
resemble to a marked degree ; sharp focusing will always bring out the 
pale fibres of mucus, thus proving that they are not hyaline casts. 




Fig. 127. — Chronic Prostatitis, with Hypertrophy of the Prostate Gland 

(X 500). 

RB, Red blood-corpuscles ; PC, pus-corpuscles containing fat-globules ; PE, epithelia 
from the prostate gland, some with endogenous new-formations; PD, epithelia from the 
ducts of the prostate gland ; UE, epithelia from the urethra with endogenous new-forma- 
tions and fat-globules ; MB, epithelia from the middle layers of the bladder with endog- 
enous new-formations; NB, epithelia from the neck of the bladder; CT, connective- 
tissue shreds; MT, mucus-threads; MC, mucus-cast; FG, free fat-globules. 



DISEASES OF THE SEXUAL ORGANS. 287 



SEMINAL VESICULITIS. 

Seminal vesiculitis, or spermatocystitis, has received considerable at- 
tention of late years by many authors, who all agree that the affection is 
of much more common occurrence than has been supposed. Although 
frequently of gonorrhceal origin, this is not the exclusive cause of the dis- 
ease, and Fuller claims that in about one- third of the cases it is tubercular 
in character. It may also be catarrhal in origin, though most authors be- 
lieve that the non-gonorrhoeal cases are rare. 

Clinical Symptoms. — The symptoms of a spermatocystitis are not al- 
ways well pronounced, and, therefore, may escape detection for years. 
Disturbances of the sexual functions are most constant, though they vary 
in different cases. In many there is a marked increase of sexual desire, 
but no relief is afforded by the coitus. This is, however, not present in 
every case, and in some there is a diminution or even absence of the de- 
sire. Pain may be present in the perineum and upon urination, and there 
may even be tenesmus. In many cases an intermittent or even constant 
discharge from the urethra, which is sometimes quite profuse, is present, 
and some patients will complain of bloody emissions. 

It will be seen that neither one of these symptoms is at all character- 
istic, and rectal examination must be resorted to. This is sometimes suc- 
cessful, but in many cases is not; when the seminal vesicles can be reached, 
they will be found distended and tender to the touch. A positive diagno- 
sis can be reached only by a microscopical examination, and the seminal 
fluid will, in all these cases, contain pus-corpuscles, and usually, especially 
in acute cases, red blood-corpuscles. 

Features Found in Urine. — The microscopical examination of the 
urine will often clear up the case. When the early morning urine, espe- 
cially the part first voided, or the last urine passed at defecation, is exam- 
ined, spermatozoa are often found. The features seen in the first morning 
urine in a case of chronic seminal vesiculitis are illustrated in Fig. 128. 

Spermatozoa are here found in large numbers. Some of them have 
the normal appearance, but others appear changed. The change takes 
place in the head of the spermatozoon, which becomes larger, round, and 
granular, and finally may resemble a pus-corpuscle, so that we seem to 
see pus-corpuscles with tails in such a urine. This change is characteristic 
of the disease, and is frequently seen, though not always in a pronounced 
degree. The originally oval head first becomes rounded and then some- 
what enlarged and granular. In milder cases no further enlargement 
takes place, while in the more intense cases a number assume the size of 
pus-corpuscles, being either coarsely or finely granular. Such a diagnosis 



288 UBINABT ANALYSIS AND DIAGNOSIS. 

of changed spermatozoa should be made only when they are distinct and 
unbroken, their heads and tails being intact. Broken and distorted heads 
of spermatozoa, also seen in chronic seminal vesiculitis, are useless for a 
diagnosis, since they may become broken in urine under normal condi- 
tions. 

Besides the spermatozoa, pus-corpuscles are always found in such a 
urine, and may be either scanty or numerous, according to the degree of 
inflammation. Since suppuration not infrequently occurs in the seminal 
vesicle, pus-corpuscles may be very numerous. Red blood-corpuscles are 
almost always present, though their number also varies considerably, 
being abundant in the more pronounced and scanty in the milder or the 
chronic cases. 

Epithelia from the seminal vesicles and ejaculatory ducts can always 
be found. The former are small, irregular, non-ciliated; the latter are 
originally columnar ciliated epithelia, in some of which the cilia will be 
seen, while in others they are broken off. When they are broken, delicate 
parallel rods in the interior of the epithelia, near their basal surfaces, may 
indicate that the epithelia were originally ciliated. 

In all cases examined, epithelia from the prostate gland were present, 
showing that the prostate gland was also inflamed. The numbers of pros- 
tatic epithelia will, however, vary considerably, though they are usually 
fairly abundant, both the cuboidal and columnar epithelia being seen. In 
the more chronic cases fat-globules are found, both in the epithelia and 
lying free. Mucus is always greatly increased in these cases, and cylin- 
droids or mucus-casts may be numerous; the mucus-threads sometimes 
assume large sizes. When suppuration exists, connective-tissue shreds 
are always present. Epithelia from the urethra and the bladder may 
accompany the other features. 

Hemorrhage from the Seminal Vesicles. — Hemorrhages from the 
seminal vesicles are not rare, and may be due to traumatism of any kind, 
as well as to tuberculosis and gonorrhoea. Such a hemorrhage may be 
primarily caused by excesses in venery, as in the case depicted in Fig. 129, 
in which it immediately followed excessive sexual indulgence in a previ- 
ously strong, healthy man, continued for some time, and was followed by 
an inflammation of the vesicles and prostate gland. 

When this urine was examined under the microscope, all the evidences 
of an active hemorrhage were present: red blood-corpuscles, partly cre- 
nated and partly lying edgewise, being abundant, and small haemato- 
blasts also being found in moderate numbers; besides these, strings of 
fibrin were seen in different fields. Small, irregular, columnar epithelia 
from the seminal vesicles, some of which contained pigment granules, 
were present in small to moderate numbers, and a few longer, slender, 



© 




tm © 



4& 



® 





MT 



ED 

■KB 



ES 
FG 



Fig. 128. — Chronic Sperm atocystitis, or Seminal Vesiculitis (X 500). 

RB, Red blood-corpuscle; PC, pus-corpuscles; NS, normal spermatozoa; ES, sperma- 
)zoa with enlarged and granular heads; SV, epithelia from the seminal vesicles; ED, 
pithelium from the ejaculatory ducts; PE, epithelia from the prostate gland; PD, epi- 
lelia from the ducts of the prostate gland; MT, mucus-thread; MC, mucus-cast; FG, 
*ee fat-globules. 




Fig. 129. — Hemorrhage from Seminal Vesicles, with Acute Prostatitis 

(X 500). 

RB, Red blood-corpuscles ; H, Haematoblasts ; WC, white blood-corpuscles ; PC, pus- 
corpuscles; SV, epithelia from the seminal vesicles; ED, epithelia from the ejaculatory 
ducts; PE, epithelia from the prostate gland; PD, epithelium from the ducts of the 
prostate gland; F, strings of fibrin; CT, connective-tissue shred; MT. mucus-thread. 



DISEASES OF THE SEXUAL ORGANS. 293 

partly ciliated epithelia from the ejaculatory ducts were also found. Be- 
sides these features, the specimen contained pus-corpuscles, connective- 
tissue shreds, mucus-threads, and cuboidal and columnar epithelia from 
the prostate gland and its ducts, showing a prostatitis. 

In an active hemorrhage of this kind, white blood-corpuscles or leuco- 
cytes are invariably present. These cannot be differentiated from pus- 
corpuscles, and, as long as they are seen in small numbers only, the pres- 
ence of the latter must not be diagnosed. As soon as these corpuscles are 
found in moderate numbers, some are undoubtedly pus-corpuscles, and 
the existence of an inflammation besides the hemorrhage then becomes 
plain. 

VAGINITIS. 

Inflammations of the vagina, especially mild chronic cases, are of 
common occurrence and have little significance, the only symptom being 
a slight discharge; few women who have borne children are entirely free 
from this affection. The severer cases may be due to many causes, such 
as exposure to cold, gonorrhceal infection, or injuries of any kind, or may 
be secondary to an inflammation of the uterus. 

Features Found in Urine. — It is rare that in the urine of a female vag- 
inal epithelia are not found in greater or less amount. Epithelia from 
the upper layers are shed in a small amount in perfect health, and have 
no significance; such epithelia may be seen even in small children. So 
long as the flat epithelia from the upper layers are present alone in small 
numbers, without cuboidal epithelia from the middle layers and without 
pus- corpuscles, the diagnosis of a vaginitis cannot be made. As soon, 
however, as large cuboidal epithelia are also present, a pathological proc- 
ess of some kind exists in the vagina. 

Catarrhal Vaginitis. — The common forms of vaginitis seen in the 
urine are the mild chronic cases, and the features found are shown in Fig. 
130. 

Pus-corpuscles are always present, but usually in small numbers only. 
Epithelia from the upper and middle layers of the vagina are quite nu- 
merous. These epithelia are considerably larger than those from the blad- 
der, the upper layers being flat, the middle cuboidal. Epithelia from the 
upper layers are frequently studded with bacilli and cocci, and often con- 
tain variously sized extraneous fat-globules. They may be found in 
groups, which may fill the greater part of the field. Cuboidal epithelia 
from the middle layers, which in urine usually appear round or oval, 
though they vary in size sometimes to a great degree, are always larger 
than those from the bladder, and may also be found in groups. Colum- 



294 URINARY ANALYSIS AND DIAGNOSIS. 

nar epithelia from the deepest layer are not seen in these milder cases, 
but only in severe inflammations or ulcerations. 

Besides these epithelia, small cuboidal epithelia, twice the size of pus- 
corpuscles and exactly similar to those from the prostate gland in the 
male, are usually present; these are the epithelia from the Bartholinian 
gland and denote a slight Bartholinitis. 

Pus-corpuscles, as well as the different epithelia, contain small fat- 
globules in varying numbers in all chronic cases. Free fat-globules may 
also be seen. In most, if not in all cases of vaginitis, micro-organisms, 
both cocci and bacilli, are found, and are, as a rule, quite abundant. 
Their presence has no significance, as it is well known that micro-organ- 
isms always exist in the vagina, the more pronounced if an inflammation 
has developed. The characteristics here described are usually seen in 
urines examined for other reasons and containing other features. 

In acute vaginitis red blood-corpuscles as well as pus-corpuscles will 
be abundant, and vaginal epithelia from the different layers quite numer- 
ous. In simple catarrhal vaginitis the flat and cuboidal epithelia are usu- 
ally present alone, while in vaginitis due to gonorrhoea, and especially in 
ulcerative vaginitis, columnar epithelia from the deepest layer are also 
found, and connective-tissue shreds are present in varying amount. 

Ulcerative Vaginitis. — The features of ulcerative vaginitis, as seen 
in urine, are shown in Fig. 131. Flat epithelia from the upper layers, 
cuboidal epithelia from the middle layers, and columnar epithelia from 
the deepest layer of the vagina are here seen in moderate numbers, while 
pus-corpuscles and red blood-corpuscles are fairly numerous. Connec- 
tive-tissue shreds of varying sizes are present, and some of these are sur- 
rounded by micro-organisms in the form of zooglcea-masses. Mucus- 
strings and cylindroids, the latter at times difficult of differentiation from 
hyaline casts, are also seen, while different micro-organisms, both micro- 
cocci and bacilli, are scattered throughout the specimen. Epithelia from 
the Bartholinian gland may be quite abundant. 

Besides catarrhal and ulcerative vaginitis, traumatic vaginitis due to 
masturbation may be diagnosed from urine. Here pus-corpuscles are 
present in small numbers only, and red blood-corpuscles are not numer- 
ous; but epithelia from all the layers of the vagina are abundant, the 
cuboidal from the middle layers and the columnar from the deepest layer 
being well marked. Epithelia from the Bartholinian gland are also seen 
in moderate numbers. Epidermal scales, showing corrugated edges, 
studded with fat-globules and dirt particles, and faintly granular, if at 
all, are seen in every field. These are derived from the clitoris and 
nymphae. Connective-tissue shreds are also seen, though they are not 
numerous. Micro-organisms and a few fat-globules complete the features. 






MV 




MV 



Fig. 130. — Chronic Catarrhal Vaginitis (X 500). 
PC, Pus-corpuscles containing fat-globules; UV, epithelia from the upper layers of the 
vagina; MV, epithelia from the middle layers of the vagina, containing fat-globules; 
BG, epithelia from the Bartholinian gland; FG, free fat-globules; B, bacilli: M, micro- 
cocci. 




Fig. 131. — Ulcerative Vaginitis (X 500). 
RB, Red blood-corpuscles ; PC, pus-corpuscles ; UV, epithelia from the upper layers 
of the vagina; MV, epithelia from the middle layers of the vagina; DV, epithelia from 
the deepest layer of the vagina; BG, epithelia from the Bartholinian gland; CT, con- 
nective-tissue shred; ZC, zoogloea-masses surrounding connective-tissue shreds; MT, 
mucus- thread ; MC, mucus-cast ; Z, zoogloea-mass ; M, scattered micrococci ; St, Strepto- 
cocci pyogenes; B, bacilli. 



DISEASES OF THE SEXUAL ORGANS. 299 

Whenever epithelia from the deepest layer and connective-tissue 
shreds are present, we have all the evidences of a destructive process. 
Continuous irritation or injury to the parts by masturbation is sufficient 
to produce these features in small numbers. If an ulcer exists, the pus- 
corpuscles and epithelia are more numerous ; and if traumatism results in 
hemorrhage, red blood-corpuscles are more abundant, The features here 
described may be found accidentally when a urine is examined for other 
pathological conditions, and when seen in that of young girls should al- 
ways lead to a suspicion of masturbation. The cause of a nervous irri- 
tability or neurasthenia is thus not rarely cleared up. 

CERVICITIS AND ENDOMETRITIS. 

Cervicitis and endometritis may also be diagnosed from the urine, 
when the different epithelia from the cervix and mucosa of the uterus are 
present. Epithelia from the cervix uteri are quite large and irregular, 
while those from the mucosa uteri are columnar ciliated. Both are shown 
in Fig. 122. The other features of such an inflammation are similar to 
those seen in any inflammation. In ulcerations or injuries shreds of 
connective tissue are found. In endometritis we occasionally see pus- 
corpuscles with cilia from the mucosa uteri, together with the ciliated 
epithelia 

Tumors from the uterus can be diagnosed from examination of the 
urine in rare cases only, when a small particle of the tumor is cast off and 
found in the urine. The features of the tumor are similar to those previ- 
ously described, and the character of the epithelia will determine the seat 
of the tumor. 



CHAPTER XIX. 

DETERMINATION OF THE FUNCTIONAL EFFICIENCY OF 
THE KIDNEYS. 

With a view of determining the functional efficiency of one or of both 
kidneys, different methods have of late years been described, which may 
at times be valuable as aids to the chemical and microscopical examina- 
tion of urine, but which, in the present state of our knowledge, are not 
sufficiently accurate to be of considerable clinical value. The determina- 
tion of the function of one or of both kidneys is of importance not only 
for the diagnosis, but also for the prognosis of many cases, and the re- 
moval of one kidney should never be decided upon until the surgeon has 
satisfied himself that the second kidney is in a sufficiently healthy condi- 
tion to be able to perform the work of the other kidney. 

Undoubtedly the best method for the determination of this vitally 
important point is the one of obtaining the separate urines from the right 
and the left kidney by the ureteral catheter, or, if it is impossible to obtain 
the urine in this manner, by means of one of the segregators. Each urine, 
which should be collected simultaneously and for the same period of time, 
should then be carefully examined chemically and microscopically, and 
in the majority of cases the condition of each kidney can thus be ascer- 
tained. Not only will the character of the pathological process in one or 
both kidneys become plain, but to a great degree the extent of the lesion, 
as well as the constitution of the patient at the time of the examination, 
thus, showing whether his organism is able to withstand the necessary 
surgical procedures. 

Of the special methods which are used for the determination of the 
renal function, cryoscopy, the methylene-blue test, the phloridzin test, 
and the toxicity test are the more important. 

Cryoscopy, the determination of the freezing-point of the urine and 
blood, is based upon the observations of Raoult that the freezing-point 
of a solution varies in proportion to the number of molecules it contains. 
The greater the number of molecules, the lower the freezing-point. The 
freezing-point of a solution is compared with that of distilled water, which 
freezes at 0° C. : urine in health freezes at —0.9° C. to —2.6° C; the 
freezing-point of blood is between — 0.56° and — 0.5S° C. If there is a 
pathological process of the kidneys, interfering with their functional ac- 

301 



302 URINARY ANALYSIS AND DIAGNOSIS. 

tivity, the freezing-point of urine rises, because the total number of mok 
cules excreted is diminished ; the freezing-point of blood at the same time 
is correspondingly lowered, since it possesses higher molecular concen- 
tration on account of the retention of excrementitious products. If on< 
kidney only is diseased, while the other kidney performs its proper func- 
tion, the freezing-point of blood is not materially altered. If the latter k 
much below — 0.60° or — 0.62° C, the removal of one kidney is claimed 
to be contraindicated, as the patient is likely to die from uraemia, al- 
though successful operations have been reported upon persons whose 
blood froze below —0.60° C. 

The apparatus used for freezing-point determinations is Beckman's 
cryoscope, although a number of modifications have been described. It 
consists of a test tube for the urine or blood, into which the bulb of a very 
delicate thermometer, graduated to one-one-hundredth of a degree, clips. 
Outside of this is another test tube, containing alcohol or a solution of 
glycerin, which stands in a glass jar containing the freezing mixture. 
Two stirring rods are intended constantly to stir the freezing mixture and 
the liquid to be tested. When the fluid approaches the freezing-point, 
the mercury begins to fall ; it then rises and fluctuates for a time, until it 
finally settles at a point below zero, which corresponds to the freezing- 
point of the liquid. Distilled water should be used first. 

Although cryoscopy may be of value in different cases for the diagno- 
sis of renal insufficiency, it cannot be considered entirely trustworthy, as 
there are at present many conflicting statements by different observers. 
At best, the method may be used as corroborative evidence when other 
methods are also employed. 

Methylene-blue Test. — When methylene-blue is injected into the tis- 
sues, it normally appears in the urine in from fifteen to thirty minutes, 
and continues to be eliminated for a number of hours. Five centigrams 
of methylene-blue are used for the injection into the gluteal muscles, and 
the substance appears in the urine partly in its original form, coloring 
the urine green or bluish-green, partly in the form of a colorless chromo- 
gen, which is converted into the pigment by heating the urine with acetic 
acid. If the kidneys are diseased, the excretion of the methylene-blue is 
delayed, sometimes for two hours or longer. This test is by no means 
exact, as small amounts of healthy kidney substance, which may exist in 
even extensively diseased organs, may suffice for a prompt appearance of 
the coloring matter in the urine. 

Phloridzin Test. — After the injection of 1 to 5 cgm. of phloridzin 
subcutaneously, sugar will appear in the urine in fifteen to thirty min- 
utes in healthy persons, and continue for two to three hours. When the 
kidneys are diseased, the excretion of sugar is diminished or does not take 



FUNCTIONAL EFFICIENCY OF THE KIDNEYS. 303 

place at all. As some observers state that the excretion is never uni- 
form, even in health, the test is of no practical value. 

Toxicity Test. — In health, urine is poisonous when injected into ani- 
mals, such as rabbits; but this toxicity varies even under normal condi- 
tions. In pathological conditions the toxic power of the urine may be 
diminished or increased. In different fevers it is usually increased, while 
in nephritis it is diminished, and the urine is claimed to be non-poisonous 
when the renal lesion is extensive. The practical results obtained by this 
method are extremely small. 

Electric Conductivity. — Another method which has been employed, 
is the estimation of the electric conductivity of the urine. This method 
is based upon the fact that the power of a solution to conduct a current 
varies with its molecular concentration; it is, however, of very slight 
practical value. 



i 



APPENDIX. 

When many urine examinations are made, it is a good plan to have a 
printed blank for such examinations, which, or a copy of which, is filed 
away for future reference. As in the great majority of cases only the 
more important chemical tests are necessary, these alone should be in- 
corporated in the blank, leaving space for any special examination to be 
made in certain cases. The following blank can be used for all purposes: 



Report on Examination of Urine. 



Marked. . . 
From Dr. . 
Received . 
Examined 



Physical and Chemical Examination. 



Passed 

Total in twenty-four hours . 

Reaction 

Color 

Odor 

Sediment 

Specific gravity 

Urea 

Urates 

Phosphates 

Sulphates 

Chlorides 

Carbonates. . 

Albumin 

Sugar 

Acetone 

Diacetic acid. 

Bile 

Indican 

Blood 

Other chemical elements . . 
Total solids 



Microscopical Examination. 
Crystalline and amorphous sediments 



Red blood-corpuscles 

Pus-corpuscles , 

20 305 



306 APPENDIX. 

Epithelia : 

Convoluted tubules of kidney 

Straight collecting tubules of kidney 

Pelvis of kidney 

Ureter 

Bladder 



Urethra 

Prostate 

Seminal vesicles. 

Vagina 

Other epithelia. . 



Tube casts. 



Pseudo-casts 

Connective-tissue shreds. 

Mucus 

Micro-organisms 

Spermatozoa 

Other features 



Diagnosis 

Constitution 

Remarks 

In filling out the blank the numbers of the different microscopical ele- 
ments should be stated, and the following terms may be used: 
None. 
Very few. 
Few. 

Few to moderate. 
Moderate. 
Fairly numerous. 
Numerous. 
Very numerous. 

Whenever albumin and sugar are present, the approximate percentage 
amounts should, if possible, be stated. When this cannot be done, the 
following terms may be used: 

Faint trace. 

Trace. 

Small amount. 

Moderate amount. 

Large amount. 

Very large amount. 

These terms may also be employed to determine the amounts of bile, 
indican, and other chemical elements. 



INDEX. 



Abbe condenser, 67 
Abscess of kidney, 218 
Abscess of pelvis of kidney, 222 
Abscess of prostate gland, 278 
Accidental albuminuria, 36 
Acetic acid test for albumin, 36 
Aceto-acetic acid, 54 
Acetone, 53 

Acid sediment in fermentation, 89 
Acid sediments, 69 
Acid sodium pbosphate, 13 
Actinomyces, 159 
Actinomycosis, 159 
Acute abscess of kidney 221 
Acute catarrhal cystitis, 250 
Acute catarrhal nephritis, 193 
Acute croupous exacerbations, 217 
Acute croupous hemorrhagic nephri- 
tis, 205 
Acute croupous nephritis, 202 
Acute interstitial nephritis, 193 
Acute parenchymatous nephritis, 202 
Acute prostatitis, 277 
Acute suppurative nephritis, 221 
Acute suppurative prostatitis, 278 
: Acute suppurative pyelitis, 222 
Acute ulcerative cystitis, 257 
Acute urethritis, 275 
Acute vaginitis, 294 
Adenin, 26 
Aerometer, 17 

Afferent vessels of glomerulus, 5 
Air-bubbles, 173 
Albumin, 35 
Albuminometer, 40 
Albuminous substances, 35 
Albuminuria, 35 
Albuminuria, functional, 36 
Albumose, 42 
Alimentary glycosuria, 46 
Alkaline change of acid urine, 90 
Alkaline sediments, 69, 83 



Alkali phosphates, 30 

Alloxan, 25 

Alloxuric bases, 25 

Almen's guaiacum test for haemoglobin, 
58 

Amidopurin, 26 

Ammonio-magnesian phosphates, 83 

Ammonium purpurate, 25 

Ammonium urate, 88 

Ammonium urate in statu nascenti, 76 

Amoeboid changes of pus corpuscles, 
101 

Amorphous sediments, 69 

Amorphous simple phosphates, 86 

Amount of solids, 19 

Amount of urine, normal, 14 

Amount of urine, pathological, 17 

Amphoteric reaction, 13 

Amyloid corpuscles of prostate gland, 
115 

Amyloid degeneration of kidney, 186, 
211 

Amyloid disease of kidney, 211 

Anatomical structure of kidney, 182 

Aniline color, 152 

Aniline water, 153, 156 

Aniline water fuchsiu solution, 156 

Aniline water gentian violet solution, 
153 

Animal inoculations, 158 

Animal parasites, 160 

Anomalies of secretion, 229 

Antiseptic substances, use of, 66 

Anuria, 17 

Appearance of urine in cystitis, 250 

Appearance of urine in malignant tu- 
mors of kidney, 243 

Appendix, 305 

Arched tubule, 2 

Aromatic sulphates, 31 

Arterial arches, 5 

Ascaris lumbricoides, 164 



307 



308 



INDEX. 



Ascitic fluid, 155 

Aspergilli, 148 

Atrophy of kidney, 131, 212 

Bacillus subtilis, 151 
Bacillus ureoe, 150 

Bacteria, development of, in urine, 16 
Bacterial casts, 146 
Bacterium coli commune, 159 
Bacterium termo, 150 
Bacterium urese, 150 
Bacteriuria, 147 

Bartholinian gland epithelia, 120 
Basidia, 148 

Beckman's cryoscope, 302 
Bence- Jones albumose, 43 
Beta-oxybutyric acid, 54 
Bile acids, 57 
Bile pigments, 56 
Bilharzia hsematobia, 162 
Bilirubin, 94 

Biuret reaction for albumin, 39 
Bladder, cancer of, 268 
Bladder, diseases of, 248 
.Bladder epithelia, 107 
Bladder, inflammations of, 248 
Bladder, papilloma of, 264 
Bladder, parasites in, 272 
Bladder, sarcoma of, 268 
Bladder, tumors of, 264 
Blank for urine examination, 305 
Blood-casts, 137 
Blood-clots, 99 
Blood-corpuscles, 97 
Blood-serum agar, 155 
\Bottger's test for sugar, 49 
Bowman, capsule of, 1 
Bowman, views of, 6 
Brick-dust sediment, 17, 71 
Bright's disease, 181 
Budding of yeast fungi, 149 

Calcium carbonate, 90 

Calcium carbonate concretions, 96 

Calcium oxalate, 76 

Calcium oxalate concretions, 95 

Calcium phosphates, 86 

Calcium sulphate, 83 

Calculi, 95 

Calyx of kidney, 2 



Cancer cf bladder, 268 

Cancer of kidney, 247 

Capsule of Bowman, 1 

Carbamic acid, 15 

Carbamide, 20 

Carbohydrates, 46 

Carbolic acid fuchsin solution, 157 

Carbonates, 33 

Carnin, 25 

Casts. See also Tubular casts. 

Casts, bacterial, 146 

Casts, cholesterin, 146 

Casts, coloring of, 136 

Casts, false, 144 

Casts, fat, 146 

Casts, fibrin, 146 

Casts from seminal tubules, 143 

Casts, haemoglobin, 137 

Casts in acute nephritis, 133 

Casts in chronic nephritis, 133 

Casts in subacute nephritis, 134 

Casts, pigment, 146 

Casts, prognostic value of, 134 

Casts, pseudo-, 144 

Casts, pus, 146 

Casts, sizes of, 134 

Casts, sodium urate, 144 

Casts, urate, 144 

Catarrhal cystitis, 250 

Catarrhal cystitis, acute, 250 

Catarrhal cystitis, chronic, 254 

Catarrhal nephritis, 188 

Catarrhal nephritis, acute, 193 

Catarrhal nephritis, chronic, 193 

Catarrhal nephritis, pathological 

changes in, 184 
Catarrhal pyelitis, 197 
Catarrhal vaginitis, 293 
Causes of anomalies of secretion, 229 
Causes o* catarrhal nephritis, 188 
Causes of chyluria, 239 
Causes of congestion of kidney, 187 
Causes of croupous nephritis, 198 
Causes of cystitis, 248 
Causes of hemoglobinuria, 234 
Causes of hyperemia of kidney, 187 
Causes of prostatitis, 276 
Causes of suppurative nephritis, 218 
Cellulose, 171 
Centrifugal analysis, 33 



INDEX. 



309 



Centrifugal method for albumin, 41 

Centrifuge, use of, 64 

Cercomonas urinarius, 165 

Cervical epithelia, 120 

Cervicitis, 299 

Changes in urine upon standing, 16, 64 

Chemical examination, 13 

Chemical sediments, 69 

Chloride of ammonium, 29 

Chloride of potassium, 29 

Chloride of sodium, 29 

Chlorides, 28 

Chlorophyl globules, 176 

Cholesterin, 92 

Cholesterin casts, 146 

Chromic acid for preservation of sedi- 
ment, 66 

Chromogens, 27 

Chronic catarrhal cystitis, 254 

Chronic catarrhal nephritis, 193 

Chronic croupous nephritis, 206 

Chronic croupous nephritis with acute 
croupous exacerbation, 217 

Chronic interstitial nephritis, 193 

Chronic parenchymatous nephritis, 206 

Chronic prostatitis, 278 

Chronic suppurative nephritis, 221 

Chronic ulcerative cystitis, 258 

Chronic urethritis, 275 

Chronic vaginitis, 293 

Chyluria, 58, 91, 163, 239 

Ciliated epithelia from ejaculatory 
ducts, 115 

Ciliated epithelia from mucosa uteri, 
121 

Ciliated pus-corpuscles, 102 

Cirrhosis of kidney, 131, 197 

Classification of nephritis, 181 

Clay water sediment, 17, 75 

Clinical symptoms of anomalies of 
secretion, 229 

Clinical symptoms of catarrhal ne- 
phritis, 189 

Clinical symptoms of croupous ne- 
phritis, 201 

Clinical symptoms of cystitis, 249 

Clinical symptoms of interstitial ne- 
phritis, 189 

Clinical symptoms of malignant tumors 
of kidnev, 243 



Clinical symptoms of parenchymatous 
nephritis, 201 

Clinical symptoms of prostatitis, 276 

Clinical symptoms of spermatocystitis, 
287 

Clinical symptoms of suppurative ne- 
phritis, 201 

Clinical symptoms of tumors of bladder, 
264 

Clinical symptoms of tumors of kidney, 
243 

Coefficient of Haeser, 19 

Colloid corpuscles of prostate gland, 
115 

Color of urine, normal, 13 

Color of urine, pathological, 16 

Coloring matter of blood, 57 

Coloring matters of urine, 15, 56 

Coloring of casts, 136 

Coloring of specimens, 151 

Columnar epithelia, 105 

Comparative sizes of pus-corpuscles 
and epithelia, 111 

Complete triple phosphates, 84 

Concentrated alcoholic fuchsin solution, 
152 

Concretions, 95 

Concretions, prostatic, 115 

Concretions, spermatic, 116 

Congestion of kidney, 187 

Conidia, 147 

Conjugate sulphates, 31 

Connective tissue, 125 

Connective tissue in atrophy of kidney, 
131 

Connective tissue in cancer, 130 

Connective tissue in cirrhosis of kidney, 
131 

Connective tissue in hemorrhage, 128 

Connective tissue in hypertrophy of 
prostate gland, 130 

Connective tissue in intense inflamma- 
tion, 131 

Connective tissue in masturbation, 12& 

Connective tissue in papilloma, 129 

Connective tissue in sarcoma, 130 

Connective tissue in stricture of ure- 
thra, 130 

Connective tissue in suppuration, 127 

Connective tissue in traumatism, 128 



310 



INDEX. 



Connective tissue in tumors, 129 

Connective tissue in ulceration, 127 

Consistency, normal, of urine, 14 

Constituents of normal urine, 15, 20 

Constitution, 102 

Convoluted tubules, epithelia from, 110 

Cork, 173 

Corn -starch, 170 

Cortical substance of kidney, 4 

Cotton fibres, 166 

Creatinin, 26, 79 

Cresol, 27 

Croupous nephritis, 198 

Croupous nephritis, pathological 

changes in, 185 
Cryoscopy, 301 
Crystalline sediments, 69 
Cuboidal epithelia, 105 
Cultivation of gonococci, 155 
Cultivation of tubercle bacilli, 158 
Culture media, 155 
Cylindrical epithelia, 105 
Cylindroids, 123 

Cystic degeneration of kidney, 212 
Cystin, 59, 79 
- C3'stin concretions, 96 
Cystitis, 248 
Cystitis, catarrhal, 250 
Cystitis, causes of, 248 
Cystitis, clinical symptoms of, 249 
Cystitis, suppurative, 258 
Cystitis, ulcerative, 257 

Decolorizing of specimens, 156 
Desquamative nephritis, 188 
Detection of acetone, 53 
Detection of albumin, 36 
Detection of albumoses, 43 
Detection of bile pigments, 57 
Detection of carbonates, 33 
Detection of chlorides, 29 
Detection of diacetic acid, 54 
Detection of fibrin, 45 
Detection of globulin, 42 
Detection of gonococci, 151 
Detection of haemoglobin, 58 
Detection of indican, 55 
Detection of lactose, 51 
Detection of levulose, 51 
Detection of mucin, 44 



Detection of peptones, 44 
Detection of phosphates, 31 
Detection of sugar, 47 
Detection of sulphates, 32 
Detection of tubercle bacilli, 151 
Detection of uric acid, 25 
Detection of urobilin, 28 
Determination of freezing-point, 301 
Determination of functional efficiency 

of kidney, 301 
Determination of reaction, 13 
Determination of solids, 19 
Development of microorganisms, 64 
Dextrose 46 
Diabetes mellitus, 46 
Diabetic acetonuria, 53 
Diacetic acid, 54 



Diagnos 
Diagnos 
Diagnos 
Diagnos: 
Diagnos 
Diagnos 
Diagnos 
Diagnos 
Diagnos 
Diagnos 
Diagnos: 
Diagnos 
Diagnos 
Diagnos: 
Diagnos 
Diagnos: 
Diagnos: 
Diagnos: 
Diagnos 
Diagnos 
Diagnos 

202 
Diagnos 
Diagnos 
Diagnos 
Diagnos 
Diagnos 
Diagnos 
Diagnos 
Diagnos 
Diagnos 
Diagnos 
Diagnos 



s of atrophy of kidney, 212 

s of cancer of bladder, 268 

s of cancer of kidney, 247 

s of catarrhal cystitis, 253 

s of catarrhal nephritis, 190 

s of cervicitis, 299 

s of chyluria, 239 

s of cirrhosis of kidney, 197 

s of congestion of kidney, 187 

s of croupous nephritis, 202 

s of endometritis, 299 

s of fistula, 176 

s of hemoglobinuria, 234 

s of hyperemia of kidney, 187 

s of interstitial nephritis, 190 

s of lithsemia, 229 

s of nephritis, 190 

s of oxaiuria, 233 

s of papilloma of bladder, 264 

s of parasites in bladder. 272 

s of parenchjmiatous nephritis, 

s of pericystitis, 263 

s of prostatitis, 276 

s of pyelitis, 198 

s of pyelo-nephritis, 193 

s of renal tuberculosis, 225 

s of sarcoma of bladder, 268 

s of sarcoma of kidney, 244 

s of spermatocystitis, 287 

s of spermatorrhoea, 284 

sof suppurative cystitis, 258 

s of suppurative nephritis, 218 



INDEX. 



313 



Diagnosis of suppurative pyelitis, 222 
Diagnosis of ulcerative cystitis, 257 
Diagnosis of urethritis, 275 
Diagnosis of vaginitis, 293 
Diagram of kidney, 3 
Diazo reaction, 55 
Diffuse inflammation, 183 
Digested muscle fibres, 176 
Diseases of bladder, 248 
Diseases of kidney and pelvis, 181 
Diseases of sexual organs, 275 
Disodium phosphate, 13 
Distal convoluted tubule, 2 
Distoma haematobium, 162 
Doremus' ureometer, 23 

Earthy phosphates, 30 

Echinococci, 161 

Efferent vessel of glomerulus, 6 

Ehrlich's diazo reaction, 55 

Eiuhorn's fermentation saccharometer, 
50 

Ejaculatory duct epithelia, 115 

Electric conductivitj^ test, 303 

Endogenous new-formations in epi- 
thelia, 109 

Endometritis, 299 

Entozoa, 160 

Epidermal scales, 106 

Epiguanin, 25 

Epithelia, 105 

Epithelia, changes of, in urine, 106 

Epithelia, columnar, 105 

Epithelia common to both sexes, 107 

Epithelia, cuboidal, 105 

Epithelia, cylindrical, 105 

Epithelia, flat, 105 

Epithelia from Bartholinian gland, 120 

Epithelia from bladder, 107 

Epithelia from cervix uteri, 120 

Epithelia from convoluted tubules of 
kidney, 110 

Epithelia from ejaculatory ducts, 115 

Epithelia from mucosa uteri, 121 

Epithelia from pelvis of kidney, 109 

Epithelia from prostate gland, 113 

Epithelia from seminal vesicles, 115 

Epithelia from straight collecting tub- 
ules of kidney, 112 

Epithelia from ureters, 110 



Epithelia from urethra, 113 
Epithelia from urine of female, 119 
Epithelia from urine of male, 113 
Epithelia from uriniferous tubules, 110 
Epithelia from vagina, 119 
Epithelia, /horny, 106 
Epithelia in normal urine, 105 
Epithelia in posterior urethritis, 114 
Epithelia, simple, 105 
Epithelia, sizes of, 106 
Epithelia, squamous, 105 
Epithelia, stratified, 105 
Epithelial casts, 136 
Esbach's albuminometer, 40 
Estimation of albumin by centrifugal 

analysis, 41 
Estimation of chlorides by centrifugal 

analysis, 33 
Estimation of phosphates by centrifugal 

analysis, 33 
Estimation of sulphates by centrifugal 

analysis, 34 
Ethereal sulphates, 27, 31 
Extraneous matters, 166 
Exudate, nature of, in inflammation, 183 

Faeces, 176 

False casts, 144 

Fat, 91 

Fat -casts, 146 

Fat -globules, 91 

Fat-granules in epithelia, 109 

Fat-granules in pus-corpuscles, 101 

Fatty casts, 140 

Fatty degeneration of kidney, 186, 206 

Fatty matters, 58 

Feather, 168 

Features found in urine in acute catar- 
rhal nephritis, 193 

Features found in urine in cancer of 
bladder, 271 

Features found in urine in catarrhal ne- 
phritis, 189 

Features found in urine in chronic ca- 
tarrhal nephritis, 194 

Features found in urine in chyluria, 240 

Features found in urine in cirrhosis of 
kidney, 197 

Features found in urine in croupous ne- 
phritis, 201 



312 



INDEX. 



Features found in urine in cystitis, 250 

Features found in urine in haemoglobin- 
uria, 234 

Features found in urine in hemorrhage 
from pelvis of kidney, 230 

Features found in urine in interstitial 
nephritis, 189 

Features found in urine in lithaemia, 229 

Features found in urine in papilloma of 
bladder, 264 

Features found in urine in parenchyma- 
tous nephritis, 201 

Features found in urine in pericystitis, 
263 

Features found in urine in prostatitis, 277 

Features found in urine in reDal tuber- 
culosis, 225 

Features found in urine in sarcoma of 
bladder, 268 

Features found in urine in sarcoma of 
kidney, 244 

Features found in urine in spermatocys- 
titis, 287 

Features found in urine in suppurative 
nephritis, 221 

Features found in urine in vaginitis, 293 

Fehleisen's streptococcus, 155 

Fehling's test for sugar, 48, 49 

Fermentation saccharometer, 50 

Fermentation tests for sugar, 50 

Fermentative changes in urine, 90 

Ferments in urine, 15 

Ferrocyanide test for albumin, 38 

Fibrin, 44, 98 

Fibrin -casts, 146 

Filaments in urine, 117 

Filaria sanguinis hominis, 163, 239 

Fission-fungi, 150 

Fistula, diagnosis of, 176 

Flaky sediment, 17 

Flat epithelia, 105 

Flaws in glass, 173 

Flocculent sediment, 17 

Fluorin in urine, 33 

Fruit-bearer in mould fungi, 148 

Fruit sugar, 51 

Fuchsin, alcoholic solution, 152 

Fuchsin, aniline-water solution, 156 

Fuchsin, carbolic-acid solution, 157 

Fuchsin, watery solution, 152 



Functional albuminuria, 36 
Functional efficiency of kidney, 301 
Fungi, 147 

Gaseous constituents of urine, 16 

General remarks, 8 

Gentian violet solution, 153 

Gerhardt's reaction for diacetic acid, 54 

Ghosts, 98 

Gleet-threads, 116 

Globulin, 42 

Glomerulitis, 184 

Glomerulonephritis, 184 

Glomerulus of kidney, 1 

Glucose, 46 

Glycerophosphoric acid, 15 

Glycosuria, 46 

Gmelin's test for bile pigments, 57 

Gonococci, 152 

Gonococci, detection of, 151 

Gonorrhoea, acute, 152 

Gonorrhoea, chronic, 154 

Gram's solution, 153 

Granular casts, 137 

Granular sediment, 17 

Granulation of pus-corpuscles, 102 

Grape sugar, 46 

Gravel, 95 

Guanin, 26 

Gunning's test for acetone, 54 

Haematoblasts, 98 

Haematoidin, 93 

Haematoidin crystals in pus-corpuscles, 

102 
Haematoporphyrin, 15, 27 
Haematuria, 57, 99 
Haemoglobin, 57 
Haemoglobin casts, 137 
Haemoglobinuria, 57, 234 
Haeser's coefficient, 19 
Haines' test for sugar, 48 
Hairs of plants, 175 
Hammarsten's table, 15 
Hay bacillus, 151 

Hayem's liquid for preservation, 67 
Heidenhain, experiments of, 6 
Heintz's method for uric acid, 25 
Heller's test for albumin, 38 
Heller's test for haemoglobin, 58 



INDEX. 



313 



Hemorrhage from gcnito-urinary organs, 

100, 128 
Hemorrhage from kidney, 188 
Hemorrhage from pelvis of kidney, 230 
Hemorrhage from seminal vesicles, 288 
Hemp-seed calculi, 95 
Henle's loop, 2 
Hetero-albumose, 43 
Heteroxathin, 25 
Hinds' modification of Doremus' ureo- 

meter, 23 
Hippuric acid, 26, 81 
Histology of kidney, 1 
Histou, 35 

Hob-nail kidney, 197 
Horismascope, 39 
Human hairs, 167 
Hyaline casts, 134 
Hydrocele agar-agar, 155 
Hydrogen dioxide, 33 
Hydropic pus-corpuscles, 101 
Hyperaemia of kidney, 187 
Hypertrophy of prostate gland, 130, 283 
Hyphse, 148 
Hyphomycetes, 147 
Hypobromite method for urea, 22 
Hypoxanthin, 26 

Incomplete triple phosphates, 85 

Indican, 55 

Indigo, 94 

Indigo concretions, 95 

Indol, 27 

Indoxyl, 27 

Indoxyl potassium sulphate, 55 

Inflammation, character of, 183 

Inflammation, diffuse, 183 

Inflammations of bladder, 248 

Inflammations of kidney, 181 

Inflammations of pelvis of kidney, 181, 

197 
Inflammatory corpuscles, 184 
Inorganic constituents, 15, 28 
Intercalated tubule, 2 
Interlobar arteries, 5 
Interlobular arteries, 5 
Interlobular veins, 6 
Interstitial nephritis, 188 
Interstitial nephritis, acute, 193 
Interstitial nephritis, chronic, 193 



Interstitial nephritis, pathological 

changes in, 184 
Introductory, I 
Iron in urine, 33 
Irritation of kidney, 184 
Isomaltose, 52 

Jaffe's test for indican, 55 

Kidney, abscess of, 218 

Kidney, amyloid disease of, 211 

Kidney, anatomical structure of, 182 

Kidney, anomalies of secretion of, 229 

Kidney, atrophy of, 212 

Kidne} r , cancer of, 247 

Kidney, catarrhal inflammation of, 188 

Kidney, cirrhosis of, 197 

Kidney, cortical substance of, 4 

Kidney, croupous inflammation of, 198 

Kidney diseases, 181 

Kidney epithelia, 110 

Kidney, fatty degeneration of, 206 

Kidney, functional efficiency of, 301 

Kidney, histology of, 1 

Kidney inflammations, 181 

Kidney, interstitial inflammation of, 188 

Kidney, large white, 206 

Kidney, malignant tumors of, 243 

Kidney, medullary substance of, 4 

Kidney, parenchymatous inflammation 

of, 198 
Kidney, sarcoma of, 243 
Kidney, secretory structure of, 6 
Kidney, suppurative inflammation of, 218 
Kidney, tuberculosis of, 225 
Kidney, vascular supply of, 5 
Kidney, waxy degeneration of, 211 
Kjeldahl's nitrogen method, 23 
Koch-Ehrlich-Weigert method of color- 
ing, 156 

Labyrinth, 3 

Lactic acid in urine, 15 

Lactose, 51 

Large white kidney, 186, 206 

Legal 's test for acetone, 53 

Lenses, 67 

Leptothrix threads, 151 

Leucin, 59, 82 

Leucorrhcea, 119 



314 



INDEX. 



Leukocytes, 98, 100 
Levulose, 51 

Lieben's iodoform test for acetone, 53 
Linen fibres, 167 
Lipuria, 58, 92 
Lithaemia, 74, 229 

Loeffler's alkaline methylene blue solu- 
tion, 152 
Loeffler's blood serum, 155 
Lycopodium, 170 

Magnesian fluid, 31 

Magnesium phosphate, 91 

Magnifying powers, 67 

Malignant tumors of kidney, 243 

Malpighian corpuscle, 1 

Maltose, 52 

Margaric acid, 92 

Materia peccans, 75 

Medullary rays, 3 

Medullar}?- substance of kidney, 4 

Melanin, 58, 95 

Methylene blue solution, 152 

Methylene blue test, 302 

Methylmercaptan, 15 

Methylxanthin, 25 

Micrococci gonorrhoeae, 152 

Micrococci in endocarditis, 155 

Micrococci in septic processes, 155 

Micrococcus urese, 150 

Micro-organisms, 147 

Micro-organisms, non-pathogenic, 147 

Micro-organisms, pathogenic, 151 

Microscopical features in acute abscess 
of pelvis of kidney or acute suppura- 
tive pyelitis, 227 

Microscopical features in acute abscess 
of prostate gland, 279 

Microscopical features in acute catar- 
rhal cystitis, 251 

Microscopical features in acute catarrhal 
pyelo-nephritis (interstitial nephritis) 
and cystitis, 191 

Microscopical features in acute croup- 
ous or parenchymatous nephritis with 
catarrhal pyelitis and cystitis, 203 

Microscopical features in acute hemor- 
rhagic croupous or parenchymatous 
nephritis with catarrhal pyelitis and 
cystitis, 207 



Microscopical features in acute ulcera- 
tive cystitis, 259 

Microscopical features in chronic catar- 
rhal cystitis, 255 

Microscopical features in chronic catar- 
rhal pyelo-nephritis (interstitial nephri- 
tis) and cystitis, 195 

Microscopical features in chronic catar- 
rhal vaginitis, 295 

Microscopical features in chronic croup- 
ous or parenchymatous nephritis with 
fatty degeneration of kidney, accom- 
panying catarrhal pyelitis and cystitis, 
213 

Microscopical features in chronic croup- 
ous or parenchymatous nephritis with 
fatty and waxy degeneration of kid- 
ney, accompanying catarrhal pyelitis, 
215 

Microscopical features in chronic croup- 
ous or parenchymatous nephritis with 
fatty and waxy degeneration of kid- 
ney, and acute hemorrhagic croupous 
exacerbation, catarrhal pyelitis, and 
cystitis, 219 

Microscopical features in chronic pros- 
tatitis, 281 

Microscopical features in chronic pros- 
tatitis with hypertrophy of prostate 
gland, 285 

Microscopical features in chronic sper- 
matocystitis or seminal vesiculitis, 
289 

Microscopical features in chronic sup- 
purative nephritis with catarrhal pye- 
litis, 223 

Microscopical features in chronic ulcera- 
tive cystitis, 261 

Microscopical features in chyluria, ca- 
tarrhal cystitis, 241 

Microscopical features in cirrhosis of 
kidney with chronic catarrhal cystitis, 
199 

Microscopical features in hsemoglobin- 
uria, acute hemorrhagic croupous or 
parenchymatous nephritis with catar- 
rhal pyelitis, 237 

Microscopical features in hemorrhage 
from bladder, due to papilloma of 
bladder, 269 



INDEX. 



315 



Microscopical features in hemorrhage 
from pelvis of kidney, due to uric acid 
calculus, 235 

Microscopical features in hemorrhage 
from seminal vesicles with acute pros- 
tatitis, 291 

Microscopical features in lithsemia with 
subacute catarrhal pyelitis and cysti- 
tis, 231 

Microscopical features in pericystitis due 
to parametritis, 265 

Microscopical features in sarcoma of kid- 
ney, chronic catarrhal pyelitis, and 
cystitis, 245 

Microscopical features in subacute croup- 
ous or parenchymatous nephritis, with 
catarrhal pyelitis and cystitis, 209 

Microscopal features in ulcerative vagin- 
itis, 297 

Microscopical features in villous cancer 
of bladder, 273 

Milk sugar, 51 

Mixed casts, 143 

Mohr's titration method for chlorides, 
29 

Mohr-Westphal balance, 18 

Monosodium phosphate, 13 

Moore -Heller test for sugar, 47 

Morbus Brightii, 181 

Morner and Sjoqvist's method for urea, 
23 

Mould-fungi, 147 

Mounting of sediment, 66 

Mucin, 44 

Mucus, 123 

Mucus-casts, 123 

Mucus-corpuscles, 123 

Mucus-threads, 123 

Mulberry calculi, 95 

Murexide test for uric acid, 25 

Muscle fibres, 176 

Mycelia, 148 

Nephritis, acute catarrhal, 193 
Nephritis, acute croupous, 202 
Nephritis, acute hemorrhagic croupous, 

205 
Nephritis, acute parenclrymatous, 202 
Nephritis, catarrhal, 188 
Nephritis, chronic catarrhal, 193 



Nephritis, chronic croupous, 206 
Nephritis, chronic croupous, with acute 

exacerbation, 217 
Nephritis, chronic croupous, with fatty 

degeneration of kidney, 206 
Nephritis, chronic croupous, with waxy 

degeneration of kidney, 212 
Nephritis, classification of, 181 
Nephritis, croupous, 198 
Nephritis, cystic degeneration of, 212 
Nephritis, desquamative, 188 
Nephritis, interstitial, 188 
Nephritis, parenchymatous, 198 
Nephritis, pathological changes in, 184 
Nephritis, subacute catarrhal, 194 
Nephritis, subacute croupous, 206 
Nephritis, suppurative, 218 
Nerves of kidney, 6 
Nitric acid test for albumin, 38 
Normal constituents of urine, 15 
Normal faeces, 176 
Normal urine, 13 
Nubecula, 16, 63 
Nuclei in pus-corpuscles, 101 
Nucleo-albumin, 44 
Nucleo-histon, 35 

Obermayer's test for indican, 55 

Odor of urine, 14 

Oidium lactis, 147 

Oil-globules, 173 

Oliguria, 17 

Organic constituents, 15, 20 

Oxalic acid, 15, 28 

Oxaluria, 78, 233 

Oxaluric acid, 15 

Oxyuris vermicularis, 165 

Papillary ducts, 1 

Papilloma of bladder, 264 

Parasites, animal, 160 

Parasites in bladder, 272 

Paraxanthin, 25 

Parenchymatous nephritis, 198 

Parenchymatous nephritis, pathological 
changes in, 185 

Pathological changes in atrophy of kid- 
ney, 186 

Pathological changes in catarrhal inflam 
rnations, 184 



316 



INDEX. 



Pathological changes in cirrhosis of kid- 
ney, 185 

Pathological changes in croupous in- 
flammations, 185 

Pathological changes in inflammations 
of kidney, 184 

Pathological changes in interstitial in- 
flammation, 184 

Pathological changes in parenchyma- 
tous inflammation, 185 

Pathological changes in suppurative in- 
flammation, 186 

Pathological urine, 16 

Pelvic epithelia, 109 

Penicillium glaucum, 148 

Peptone, 43 

Pericystitis, 263 

Perirenal abscess, 222 

Permanent microscopical specimens, 67 

Phenol, 27 

Phenylhydrazin test for sugar, 49 

Phloridzin test, 302 

Phosphates, 30 

Phosphates, significance of, 87 

Phosphates, simple, 86 

Phosphates, triple, 83 

Phosphatic concretions, 95 

Phosphaturia, 88 

Phosphoric acid, estimation of, 31 

Physical and chemical properties, 13 

Physiological glycosuria, 46 

Picric acid test for albumin, 39 

Pigment casts, 146 

Pigment granules in pus-corpuscles, 102 

Polyuria, 17 

Posterior urethritis, epithelia in, 114 

Potassium ferrocyanide test for albumin, 
38 

Potassium urate, 75 

Preservation of sediment, 66 

Preformed sulphates, 31 

Production of pus-corpuscles, 184 

Prostate gland, epithelia from, 113 

Prostate gland, hypertrophy of, 283 

Prostate gland, inflammation of, 276 

Prostate gland, tuberculosis of, 283 

Prostate gland, tumors of, 284 

Prostatic concretions, 115 

Prostatic epithelia, 113 

Prostatitis, 276 



Proteids, 35 

Proteoses, 42 

Protoalbumose, 43 

Proximal convoluted tubule, 2 

Pseudo-albuminuria, 36 

Pseudo-casts, 144 

Purin bodies, 25 

Pus-casts, 146 

Pus-corpuscles, 100 

Pus-corpuscles, derivation of, 100, 103, 

184 
Pyelitis calculosa, 233 
Pyelitis, catarrhal, 197 
Pyelitis, suppurative, 222 
Pyelonephritis, 193 
Pyknometer, 18 
Pyo-nephrosis, 218 
Pyrocatechin, 27 
Pyuria, 100 

Quantitative test for albumin, 40 
Quantitative test for sugar, 49 
Quantitative test for urea, 22 
Quantity of urine, norma], 14 
Quantity of urine, pathological, 17 

Reaction of urine, 13 

Red blood-corpuscles, 97 

Renal artery, 5 

Renal tuberculosis, 225 

Report on examination of urine, 305 

Results when urine is boiled, 37 

Rice -starch, 170 

Roberts' fermentation test for sugar, 50 

Rosenbach's test for bile pigments, 57 

Rust particles, 174 *• 

Saccharo meter, 50 
Saccharomycetes, 148 
Salts, 69 

Sarcinae urinse, 150 
Sarcoma of bladder, 268 
Sarcoma of kidney, 243 
Scales from moth, 169 
Schizomycetes, 150 
Schizomycetes, pathogenic, 151 
Scratches in cover glass, 173 
Secretion, anomalies of, 229 
Secretory structure of kidney, 6 
Sediment, brick-dust, 71 



INDEX. 



317 



Sediment, clay water, 75 

Sediment, normal, 16, 63 

Sediment, pathological, 17, 64 

Sediment, preservation of, 66 

Sedimentation glass, 63 

Sedimentum lateritium, 75 

Selection of urine, 8 

Seminal tubules, casts from, 143 

Seminal vesicles, epithelia from, 115 

Seminal vesicles, hemorrhage from, 288 

Seminal vesicles, inflammation of, 287 

Seminal vesiculitis, 287 

Serum-albumin, 35 

Serum-globulin, 35 

Silicic acid, 33 

Silk fibres, 167 

Simple epithelial lining, 105 

Simple phosphates, 86 

Skatol, 27 

Skatoxyl, 27 

Sketching of features, 68 

Smegma, 119 

Smegma bacillus, 158 

Sodium urate, amorphous, 75 

Sodium urate casts, 144 

Sodium urate, change of, 76 

Sodium urate, crystalline, 75 

Solids, determination of, 19 

Solids in urine, 15 

Solution, aniline water fuchsin,156 

Solution, carbolic-acid fuchsin, 157 

Solution, concentrated alcohol fuchsin, 

152 
Solution. Gram's, 153 
Solution, Loeffler's alkaline methylene 

blue, 152 
Solution, methylene blue, 152 
Solution, Vesuvin, 153 
Solution, Ziehl-Neelsen's, 157 
Spaeth's sedimentation glass, 63 
Specific gravity, 14 
Specific gravity, determination of, 17 
Sperma, 116 
Sperma crystals, 116 
Spermatic concretions, 116 
Spermatocystitis, 289 
Spermatorrhoea, 284 
Spermatozoa, 116, 287 
Spiegler's test for albumin, 39 
Spiral fibres from air-vessels of plants, 175 



Sporangium, 148 

Spores. 147 

Sprouting of yeast fungi, 149 

Squamous epithelia, 105 

Staphylococci pyogenes, 150, 155 

Starch-globules, 170 

Star-shaped simple phosphates, 86 

Stellate simple phosphates, 86 

Sterigmata, 148 

Stones, 95 

Straight collecting tubule, 2 

Straight collecting tubules, epithelia 

from, 112 
Stratified epithelia, 105 
Streptococci pyogenes, 150, 155 
Streptococcus of Fehleisen, 155 
Stricture of urethra, 130, 276 
Strongylus gigas, 165 
Subacute catarrhal cystitis, 257 
Subacute catarrhal nephritis, 194 
Subacute croupous nephritis, 206 
Subnitrate of bismuth test for sugar, 49 
Succinic acid, 15 
Sugar, tests for, 47 
Sulphates, 31 

Sulpho-salicylic acid test for albumin, 39 
Suppuration, 127 
Suppuration of ureter, 198 
Suppurative cystitis, 258 
Suppurative nephritis, 218 
Suppurative nephritis, pathological 

changes in, 186 
Suppurative prostatitis, 278 
Suppurative pyelitis, 222 
Surgical kidney, 218 

Test, electric conductivity, 303 

Test, methylene-blue, 302 

Test, phloridzin, 302 

Test, toxicity, 303 

Tests for acetone, 53 

Tests for albumin, 36 

Tests for albumose, 43 

Tests for chlorides, 29 

Tests for coloring matters, 57 

Tests for diacetic acid, 54 

Tests for fibrin, 45 

Tests for globulin, 42 

Tests for haemoglobin, 58 

Tests for indican, 55 



318 



INDEX. 



Tests for mucin, 44 

Tests for organic constituents, 22 

Tests for peptone, 44 

Tests for phosphates, 31 

Tests for sugar, 47 

Tests for sulphates, 32 

Tests for urea, 22 

Tests for uric acid, 25 

Tests' for urobilin, 28 

Toxicity test, 303 

Transitory glycosuria, 46 

Traumatic vaginitis, 294 

Traumatism, 128 

Trichomonas vaginalis, 160 

Triple phosphates, 83 

Trommer's test for sugar, 47 

True casts, 133 

Tubercle bacilli, 155 

Tuberculosis of kidney, 157, 225 

Tuberculosis of prostate gland, 283 

Tubular casts, 132 

Tubular casts, blood, 137 

Tubular casts, epithelial, 136 

Tubular casts, fatty, 140 

Tubular casts, granular, 137 

Tubular casts, hyaline, 134 

Tubular casts, mixed, 143 

Tubular casts, waxy, 141 

Tubules of Bellini, 2 

Tuft of kidney, 1 

Tumors, 129 

Tumors of bladder, 264 

Tumors of kidney, 243 

Tumors of prostate gland, 284 

Tumors of uterus, 299 

Twenty-four hours' collection, 8 

Typhoid bacilli, 158 

Tyrosin, 59, 82 

Ulceration, 127 

Ulceration in urethra, 276 

Ulceration of ureter, 198 

Ulcerative cystitis, 257 

Ulcerative vaginitis, 294 

Ultzman's test for bile pigments, 57 

Urate casts, 144 

Urea. 20 

Urea nitrate, 21 

Urea oxalate, 22 

Urea, quantitative test for, 22 



Ureometer, Doremus', 23 

Ureteral catheterization, 113 

Ureteral epithelia, 110 

Ureteritis, 198 

Urethral epithelia, 113 

Urethral threads, 116 

Urethritis, 275 

Uric acid, 24, 69 

Uric acid casts, 144 

Uric acid, chemical tests, 25 

Uric acid, common form, 71 

Uric acid concretions, 72, 95 

Uric acid diathesis, 72 

Uric acid from highly acid urine, 72 

Uric acid gravel, 73 

Uric acid under microscope, 70, 74 

Urinary concretions, 95 

Urinary diagnosis, 179 

Urinary pigments, 15 

Urine obtained by ureteral catheter, 

113 
Uriniferous tubules, 1 
Uriniferous tubules, epithelia from, 

110 
Uriniferous tubules, lining of, 2 
Urinometer, 17 
Urobilin, 15, 28 
Urobilinogen, 15, 28 
Urochrome, 15, 27 
Uroerythrin, 15, 27 
Urohrematin, 15 
Urometer, 17 
Uroindican, 15, 55 
Uroxanthin, 26 
Use of centrifuge, 64 
Use of antiseptic substances, 66 
Uterine epithelia, 121 

Vaginal epithelia, 119 
Vaginitis, 293 
Vaginitis, catarrhal, 293 
Vaginitis, traumatic, 294 
Vaginitis, ulcerative, 294 
Varieties of cancer of bladder, 268 
Vascular supply of kidney, 5 
Vegetable fibres, 175 
Vegetable matter, 175 
Venous arches, 6 
Vesuvin solution, 153 
Vogel's color tints, 13 



INDEX. 



319 



Water-fungi. 176 Xanthin, 26 

Watery fuchsin solution, 152 Xanthin concretion, 96 

Waxy casts, 141 

Waxy degeneration of kidney, 186, Yeast-fungi, 148 

211 
Wheat-starch. 170 
White blood-corpuscles, 98 



Ziehl-Neelsen's carbolic acid fuchsin so- 
lution, 157 



Wool fibres. 167 



Zooglcea, 150 







\* 



